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Oral Health: Approaches for general
dental practice teams on promoting oral
health
Kay E, Hocking A, Nasser M, Nield H, Vascott D, Dorr C,
Scales H
Draft Report
May 2015
Professor Liz Kay
Foundation Dean
Peninsula Dental School
Room C520
Portland Square
Drake Circus
Plymouth
Devon PL4 8AA
t
01752 586800
w www.plymouth.ac.uk
e
[email protected]
Contents
1.
Executive Summary and Evidence Statements
List of abbreviations and Glossary
Introduction
1.1
1.2
2.
3
The Need for Guidance
The Scope of the Review
i-xi
xii
1
1
2
1.2.1
Areas Covered by the review
2
1.2.2
Population Groups Covered
3
1.2.3
Outcomes
3
1.2.4
Research Questions
4
Methodology
8
2.1
Literature Search
8
2.2
Call for Evidence
9
2.3
Selection of Studies for Inclusion
9
2.4
Search Results
10
2.5
Quality Appraisal
11
2.6
Study categorisation
12
2.7
Assessing applicability
12
2.8
Synthesis
12
2.9
Strength of the evidence
12
Summary of Findings
14
3.1
3.2
14
3.3
3.4
3.5
3.6
3.7
3.8
Overall summary of studies identified
Does the application of behavioural and psychological theory to
oral health behaviour lead to effective oral health promotion
interventions?
What is the most effective mode of delivery (channel) of oral
health promotion?
3.3.1
Is verbal delivery of oral health promotion messages by
oral health professionals effective?
3.3.2
Is delivery of oral health promotion by leaflet/written
material effective?
3.3.3
Is delivery of oral health promotion by means other than
leaflet/written material effective?
What is the content of oral health messages and how does this
influence effectiveness
What influence do ‘receiver’ characteristics have on the
effectiveness of oral health promotion?
What influence do ‘sender’ characteristics have on the
effectiveness of oral health promotion messages?
What influence does framing of oral health promotion messages
have on their effectiveness?
What are the barriers and facilitators to effective oral health
promotion?
16
22
23
29
34
38
42
46
50
52
3.9
3.10
What factors affect patient satisfaction and motivation after a
dental visit?
Linking oral health messages to wider health outcomes
3.11
3.12
Discussion
Conclusion
57
59
60
61
4.
Evidence Tables
5.
References Included in the Review
395
6.
Bibliography
399
63
Appendix A
Search Strategy
400
Appendix B
Quality Assessment Checklists
403
Appendix C
Details of Excluded Studies
416
Appendix D
Smoking Cessation Studies
427
Oral Health: Approaches for general practice teams on promoting oral health
Executive Summary
This report presents the results of a review of the evidence about oral health promotion in
order to inform practice and policy in dental surgeries in the UK.
Aim
The aim of the review was to identify, critically appraise, and synthesise the available
evidence, in order to determine the circumstances in which oral health promotion is at its
most effective. The research question that guided the analysis of the data was: Is oral
health promotion effective and how can its effects be optimised?
In order to address this question the following questions were formulated:

Does the application of behavioural and psychological theory to oral health
behaviour lead to effective oral health promotion interventions?

What is the most effective mode of delivery (channel) of oral health promotion?
o
Is verbal delivery of oral health promotion effective?
o
Is delivery of oral health promotion by leaflet/written material effective?
o
Is delivery of oral health messages by means other than verbally/ in
writing effective?

What is the content of oral health messages and how does content influence
effectiveness?

What is the influence of ‘receiver’ characteristics on the effectiveness of oral
health promotion?

What influence do ‘sender’ characteristics have on the effectiveness of oral
health promotion?

What influence does framing have on the effectiveness of oral health
promotion messages?

What are the barriers and facilitators to effective oral health promotion?

What factors affect patient satisfaction and motivation after a dental visit?

Are oral health promotion messages more likely to have an effect on patients
if they are linked to wider health outcomes?
Methods
A search of bibliographic databases was used to identify any primary research, irrespective
of study design, which related to oral health messages, delivered to an adult or child, in
relation to the context of a dental practice. Twenty-four databases including those that
capture the grey literature were searched for relevant primary research including both
quantitative and qualitative designs. Initially, titles and abstracts were screened for relevance;
full papers were obtained for those articles that fulfilled the inclusion criteria, or where the
abstract lacked clarity and thus could not be excluded. Each included study was subjected to
data extraction and quality assessment, and relevant information from each study was
recorded in an evidence table.
i
Oral Health: Approaches for general practice teams on promoting oral health
We also used our professional networks and contacts, including the British Dental
Association, to issue a ‘Call for Evidence’ in order to ensure that any current or recently
completed relevant research would be included in the review. In addition, we also handsearched the references of three relevant systematic reviews, to ensure no studies were
overlooked.
Studies were grouped according to the evidence they offered in relation to the research
questions. The evidence was synthesised after considering the studies’ homogeneity, quality
and applicability and studying the evidence tables. The intention was to meta-analyse data
from studies with comparable interventions and outcome measures. Evidence was
considered strong if more than one study rated (++) or more than one Randomised
Controlled Trial (RCT) rated (+) reported an effect. Evidence for a finding was considered
moderate if supported by more than one non RCT study rated (+), and evidence was
considered weak if it was supported only by studies considered to be of low quality (-).
Results
In the main review, 44 studies reported in 52 papers were included. Fifteen of the studies
were RCTs, two were cluster RCTs, and one was a controlled trial. Also included were five
quasi-experimental studies, two before-and-after studies without control groups, three
surveys, eleven qualitative studies, three mixed methods studies, one audit and one pilot
study.
Two of the RCTS were high quality (++), ten were rated as moderate quality (+) and three
were rated (-). Both cluster RCTs were of moderate quality (+) and the controlled trial was
rated (-). Of the qualitative studies, three were appraised as high quality (++) and the
remaining eleven (which includes the qualitative parts of the three mixed methods studies)
were appraised as moderate quality (+). The before and after studies, quasi-experimental,
audit, pilot and survey studies were all rated (-) apart from one quasi-experimental study
which was high quality (++), and one survey which was methodologically sound (+).
The evidence was very disparate and the quality of reporting was highly variable. Many
studies relied on patient-reported behaviour rather than objective clinical measures or
observed behaviours. Many had short follow up periods. Similarly, it was not possible to
undertake any meta-analyses, as the homogeneity of the interventions and outcomes were
insufficient, or the outcomes were measured in units that could not be translated into
behavioural or health outcomes. Graphical representation of such heterogeneous findings
was considered inappropriate.
The heterogeneity of the populations studied, the settings and the outcomes measured in
the reviewed studies did not allow overall definitive conclusions to be drawn regarding a
single “best” way to deliver oral health promotion. Therefore, very careful consideration was
given to determining how best to group the studies in order to provide meaningful evidence
statements that could guide the development of future recommendations.
Our search strategy revealed a considerable number of studies focussing on the delivery of
smoking cessation advice. The majority of the smoking cessation studies identified were not
specifically about promoting oral health per se. It was therefore decided, in consultation with
the Centre for Public Health (CPH) team, that while we would endeavour to undertake a brief
narrative synthesis in order to be able to make a “state-of –the-art” statement about smoking
cessation advice via dental surgeries, this would not be part of the main review.
ii
Oral Health: Approaches for general practice teams on promoting oral health
Conclusions

There is strong evidence that oral hygiene and gingival health can be
improved by using psychological behaviour change models as the basis of
the intervention.

There is strong evidence that patients’ knowledge levels can be improved by
receiving oral health messages from an oral health practitioner.

There is strong evidence that leaflets and written material are effective in
promoting patients’ knowledge but there is no evidence that leaflets are
effective for changing people’s behaviour.

There is strong evidence of the existence of a number of barriers and
facilitators to the successful delivery of oral health promotion in the dental
surgery.

There is moderate evidence that patient motivation and satisfaction are
dependent on the oral health professional’s communication skills and ability to
build therapeutic alliances with their patients.

There is moderate evidence that the nature (but not the professional role) of
the ‘sender’ of oral health promotion messages and their attitudes and beliefs
about oral health promotion can act as either a barrier or facilitator to
effectiveness.

There is weak evidence that improvements in knowledge lead to improved
oral health behaviour, at least in the short term.

There is no evidence available regarding the effectiveness of linking oral
health promotion messages to wider health outcomes.
The evidence statements below have been derived from the analysis of the available data:
Application of behavioural and psychological theory
Evidence Statement 1
There is strong evidence from five RCTs reported in seven papers (2++, 2 +, 1-)1,2,3,5,6,7,8, two
quasi experimental studies4,9 (1++, 1-), and one qualitative study published in two papers10,11
(+) to suggest that the use of behavioural and psychological theoretical models in the
development of oral health promotion interventions, results in improved oral hygiene and
gingival/periodontal health. One randomised controlled trial1-3 (++) testing an oral health
promotion programme based on a cognitive behavioural approach, showed a mean gain
score difference of 0.27 for the Gingival Index in the intervention group (99.2% confidence
interval (0.16) – (0.39), p<0.001). Another RCT5 (++) which tested an intervention based on
an autonomy-supportive approach also showed significant effects on plaque reduction
(effect size -0.86, 95% confidence interval (0.81) – (0.91)) and gingivitis (effect size -1.21,
95% confidence interval (-1.18) – (1.24)). Changes in positive behaviour were also reported
in a quasi-experimental study investigating the role of cognitive behavioural therapy9 (++)
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Oral Health: Approaches for general practice teams on promoting oral health
and a qualitative study applying the transtheoretical model of behaviour change10-11 (+).
These studies did not show changes in objectively measured dental health.
This evidence is applicable to people in the UK because all of the studies were conducted in
circumstances which prevail in the UK and the models used to develop the interventions are
apposite to UK populations.
1,2,3
Jonsson et al. 2009, 2012, 2010 (++)
4
Jonsson et al. 2009 (-)
5
Munster Halvari et al. 2012 (++)
6
Kakudate et al. 2009 (+)
7
Clarkson et al. 2009 (+)
8
Little et al. 1997 (-)
9
Fjellstrom et al. 2010 (++)
10
Kasila et al. 2006 (+)
11
Kasila et al. 2008 (+)
Verbal delivery of oral health promotion
Evidence Statement 2
Two RCTs (reported in three papers) carried out in Sweden and Finland12,15,19 (1+, 1-)
showed that oral health promotion delivered verbally by dental health professionals improved
adult and child patients’ knowledge levels, and reported behaviours. However a cluster RCT
in the UK involving young children13 (+) failed to demonstrate that advice from an oral health
educator improved caries (dmf intervention = 2.65 (SD 2.5), dmf control = 3.22 (SD 2.85)) or
that it improved knowledge to a statistically significant extent (intervention score = 47, control
= 39). One RCT14 (+), in which fluoride toothpaste was also distributed, demonstrated a
reduction in caries increments (DMFS increments in intervention 2.56 (confidence interval
(2.07) – (3.05)), control 4.60 (confidence interval (3.99) – (5.21)). Size of effect for
knowledge and behaviour changes cannot be quantified/compared across studies as there is
no single accepted unit of measurement for dental health knowledge or behaviour. Three
randomised trials in Scandinavia, reported in four papers12,14,15,19 (2+, 1-), all showed that
oral health promotion delivered by an oral health professional resulted in improved oral
hygiene. A quasi-experimental study in the USA16 (-), and another in Sweden4 (-) showed
improvements in plaque, gingivitis, and reported oral hygiene behaviour. However, the USA
study showed no effect on dmft (unchanged in intervention and control groups) in the short
term (2 months). One RCT reported in two papers17,18 (-) showed an effect on caries
incidence (New Caries: Test 0.71, Control 1.91; p<0.1). This intervention included fluoride
varnish application along with motivational interviewing. One RCT in the USA20 (+) showed
that educating parents could positively influence children’s behaviour in the dental surgery
(intervention behaviour 3.62, control behaviour 3.35, p<0.05). Overall there is strong
evidence suggesting that verbal oral health promotion by dental professionals has a positive
effect on patient knowledge, behaviour and gingival health, but the effect is insufficient to
impact on caries levels unless the use of fluoride is included.
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Oral Health: Approaches for general practice teams on promoting oral health
The evidence reported is directly applicable to UK populations as disease levels, behaviour
and expected behaviours in the countries where the studies took place are largely similar to
the UK.
4
Jonsson et al. 2009 (-)
12,15
Hugoson et al. 2003, 2007 (+)
13
Blinkhorn et al. 2003 (+)
14
Hausen et al. 2007 (+)
16
Lepore et al. 2011 (-)
17,18
Weinstein et al. 2004, 2006 (-)
19
Jonsson et al. 2006 (-)
20
Wang et al. 2010 (+)
Leaflets/written materials
Evidence Statement 3
Strong evidence from four RCT UK studies, reported in six papers21-26 (4+), suggests that
leaflets are an effective way of enhancing patients’ knowledge of oral cancer and reducing
associated fear and distress. One of these studies, reported in two papers21-22 (+) showed
that knowledge in the leaflet group increased more (30.87 (95% confidence intervals (30.51)
– (31.24)) than in the control group (26.11 (95% confidence intervals (25.7) – (26.48)) effect
size 1.29). An additional RCT27 (+) presented moderate evidence that written information
had less effect than verbal delivery or video delivery when educating orthodontic patients to
improve oral hygiene (PI % change, written = 1.48, video = 12.32, verbal = 18.7).
A UK audit study by Wanless28 (-) described how the readability of written oral health
promotion material might be improved and a qualitative study29 (+) indicated that young
males considered written information to be purely functional and impersonal.
There is therefore strong evidence that leaflets are effective for increasing patient
knowledge, but some weak evidence that they are less effective than other modes of
delivery. They are potentially less acceptable to patients than personal delivery of
information. No evidence was identified suggesting that oral health promotion in leaflets
affect health outcomes.
This evidence is applicable to patients attending dental practices in the UK as this setting
was relevant to the majority of these studies.
21,22
Humprhis et al. 2003, 2004 (+)
22
Humpris et al 2004 (+)
23,24,25
Humphris et al. 2004, 2001, 2001 (+)
26
Boundouki et al. 2004 (+)
27
Lees et al. 2000 (+)
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Oral Health: Approaches for general practice teams on promoting oral health
28
Wanless. 2001 (-)
29
Ashford. 1998 (+)
Other methods of delivery
Evidence Statement 4
4.1 Group discussions
There is strong evidence of the effectiveness of group discussions compared to standard
oral health promotion from a cluster RCT30 (+) carried out in Thailand, which involved
mothers of children aged 6-19 months. Both intervention and control groups received dental
health education and toothbrushes. The intervention group also participated in group
discussions conducted by trained moderators, which lasted about one hour. Group
discussions may be an effective adjunct to traditional dental health education in altering
behaviours, as 20% more mothers in the study reported that their child’s teeth were brushed.
The intervention did not have any effect on caries levels.
This evidence is probably not applicable to patients attending general dental practices in the
UK as group discussions with mothers of young children do not fit with the current model of
service delivery in the UK.
4.2 Technology
There is weak evidence concerning the use of technology for oral health promotion from a
small pilot study by O’Hara31 (-), in which 36 people with intellectual disabilities and poor
oral and general health were taught to use personalised digital assistants (PDAs), which
reminded and prompted them to undertake oral hygiene practices. The effectiveness of the
intervention was assessed by gathering anecdotal evidence from support care staff and by
the individuals by measuring oral health status using a 4 point scale. More than half of the
participants had difficulty with the technology, and 11 of 36 participants dropped out of the
study. Of the remaining 25, ten achieved improvement in oral health. There is therefore no
evidence that technology can be used to promote oral health in general practice.
The findings from this small study may not be applicable to the majority of people attending
general dental practices.
4.3 Clinical intervention with advice
There is weak evidence from a study in Australia32 (-), in which high risk young adult patients
(aged 18-35) underwent assessment of fortnightly coaching in oral hygiene and topical
fluoride. 20 patients, who were examined after six months attained and maintained lower
plaque levels, had decreased gingival inflammation, and had reduced rates of caries
progression. This study offers weak evidence that intensive oral hygiene instruction and
fluoride application can improve oral health.
However, the evidence is only partially applicable to the UK population attending general
dental practices due to differences between the UK and Australian system for dental care.
30
Vachirarojpisain et al. 2005 (+)
31
O’Hara et al. 2008 (-)
vi
Oral Health: Approaches for general practice teams on promoting oral health
32
Sbaraini et al. 1994 (-)
Message content and effectiveness
Evidence statement 5
Strong evidence about the content of oral health promotion was derived from six studies,
four of which were carried out in the UK (one study was reported in two papers)33-37 (3+, 1-),
one in Israel38 (-), and one in Sweden39 (++). These studies explored the content of oral
health promotion which is given in general practices. None of these studies examined the
effectiveness of the oral health promotion. One study37 (-) indicated that 28% of the advice
given about fluoride did not comply with British Society of Paediatric Dentistry guidelines and
another study36 (+) showed that 32% of practitioners were likely to give advice which did not
comply with official guidance. Two qualitative studies34,35,39 (1+, 1++) showed that the content
of the oral health promotion advice given, depended on the practitioner’s view of what the
receiver might be receptive to. Two studies33,38 (1+, 1-) indicated that oral hygiene instruction
was the preferred route for giving advice.
There is therefore moderate evidence that the content of oral health promotion messages
given in practice does not always accord with guidelines and official advice. There is
moderate evidence that content is tailored to the patients’ needs, expectations and apparent
motivations. There is no evidence as to how the content of oral health promotion impacts its
effectiveness, as none of the studies exploring content assessed the impact of content on
effectiveness.
This evidence is applicable to dental practice in the UK.
33
Holloway et al. 1994 (+)
34,35
Threlfall et al. 2007 (+)
36
Witton et al. 2013 (+)
37
Harris et al. 2002 (-)
38
Ashkenazi et al. 2014 (-)
39
Jensen et al. 2014 (+
Influence of receiver characteristics
Evidence Statement 6
There is weak evidence from one controlled clinical trial40 (-), a before and after study41 (-)
and four qualitative studies42-45 (4+), suggesting that oral health promotion, especially
designed for very specific receiver groups, is effective in improving knowledge and attitudes.
Two Canadian studies43-44 (2+) using qualitative methodology, and one in Finland40 (-) using
quantitative methods, explored oral health promotion with deprived individuals. These
studies suggest that an understanding of the social context of oral health and the
development of relationships/collaborations are a vital part of developing oral health
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Oral Health: Approaches for general practice teams on promoting oral health
promotion interventions for the underprivileged. Three studies, one carried out in Australia,
and two in America, examined oral health promotion for very specific special groups –
intellectually disabled42 (+), HIV positive individuals45 (+), and scleroderma patients41 (-). An
emergent theme from these studies is the need for collaboration and understanding between
professional and receiver groups. Thus, there is moderate evidence that the perceptions of
the receiver regarding their relationship with the sender, and the senders’ understanding of
the context of the receivers’ lives and behaviour, are relevant to their acceptance and
likelihood of acting upon oral health promotion messages.
These studies were all conducted outside of the UK so the results may only be partially
applicable to people attending dental practices in the UK, as the cultural and economic
provision for dental care for groups with special needs differs in North America, Australia,
and the UK.
40
Meurman et al. 2009 (-)
41
Poole et al. 2010 (-)
42
Grant et al. 2004 (+)
43
Levesque et al. 2009 (+)
44
Loignon et al. 2010 (+)
45
Rajabiun et al. 2012 (+)
Influence of ‘sender’ characteristics
Evidence Statement 7
Evidence regarding the affect of sender characteristics was identified in four papers
including one quantitative46 (-) and three qualitative39,47,48 (2+, 1++) studies. These studies
explored aspects of the ‘sender’s’ influence on oral health promotion and how the sender
affects its potential effectiveness. A quantitative questionnaire study by Schouten46 (-), which
measured satisfaction with communication, gave weak evidence that a receiver’s responses
were influenced by the dentist’s ability to communicate. A qualitative study48 (+)
demonstrated that dentists who were networked to other oral health professionals, and
committed to prevention were more positive about oral health promotion. Another qualitative
study carried out in Sweden39 (++), showed that oral health professionals often assume that
patients have sufficient knowledge from other sources and do not need further advice. Two
studies39.48 (1++, 1+) suggested that holistically-thinking, health focussed (as opposed to
curative disease focused) professionals were more positive about oral health promotion.
There is therefore moderate evidence from qualitative studies to suggest that the beliefs,
attitudes and values of oral health professionals influence the likelihood of them participating
in and being positive about oral health promotion. No studies directly compared the
effectiveness of oral health promotion given by different members of the dental team,
therefore there is no evidence concerning the comparative effectiveness of different oral
health staff on the effectiveness of oral health promotion.
The evidence above is considered applicable to oral health promotion given in UK general
dental practices.
39
Jensen et al. 2014 (++)
viii
Oral Health: Approaches for general practice teams on promoting oral health
46
Schouten et al. 2003 (-)
47
Brocklehurst et al. 2013 (+)
48
Dyer et al. 2006 (+)
Influence of framing
Evidence Statement 8
There is weak evidence from one study49 (-) to suggest that the framing of oral health
promotion messages should be positive. This study examined the influence of message
framing and credibility on the receiver’s attitudes and intentions in the context of oral health.
This paper applied theories and previous study results to the oral health context. The study
suggested that the application of prospect theory (in which decision making is affected by
the perceived value of outcomes in the future) would imply that in relation to oral health
service usage, messages should be framed negatively (in terms of losses if the behaviour is
NOT taken up), but that health promoting messages should be framed positively (in terms of
benefit if the suggested behaviour IS taken up).
This study is probably only partially applicable to the UK as it was carried out in the US and
focused on attending a dental practice for an examination. Dental attendance is perceived
differently in the UK and USA and therefore the applicability may be limited.
49
Arora. 2000 (-)
Barriers and facilitators
Evidence Statement 9
Strong evidence from 11 studies; seven qualitative, two surveys, and two mixed method
studies (1++, 9+, 1-) define barriers and facilitators to oral health promotion. Three
qualitative studies reported in four papers34,35,39,48 (1++, 2+) showed that dentists gave
messages which accorded with their own experiences and prejudices, and there was
moderate evidence that the sender’s belief in the credibility and effectiveness of oral health
messages affected the likelihood of them conveying them to the patient. The oral health
professional’s level of understanding of the ‘receiver’ was shown in four studies29,39,47,48 (1++,
3+) to act as a barrier or facilitator to effectiveness, and two studies39,48 (1++, 1+) showed
that if the sender felt commitment to, and enjoyment/satisfaction when promoting oral health,
this would act as a facilitator. There was also moderate evidence from three qualitative
studies42,44,45 (3+), that any pejorative or judgemental views held by the sender, concerning
the receiver of the message, would act as a barrier to oral health promotion. Three
studies38,48,50 (2+, 1-) indicated that lack of appropriate resources (knowledge, staff, time,
space) act as barriers to the delivery of effective oral health promotion.
This evidence is likely to be directly applicable to the UK situation.
29
Ashford. 1998 (+)
34,35
Threlfall et al. 2007 (+)
36
Witton et al. 2013 (+)
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Oral Health: Approaches for general practice teams on promoting oral health
38
Ashkenazi et al. 2014 (-)
39
Jensen et al. 2014 (++)
42
Grant et al. 2004 (+)
44
Loignon et al. 2010 (+)
45
Rajabiun et al. 2012 (+)
47
Brocklehurst et al. 2013 (+)
48
Dyer et al. 2006 (+)
50
Williams et al. 2011 (+)
Factors affecting satisfaction and motivation
Evidence statement 10
Three papers (one quantitative46 and two qualitative51,52) offered evidence regarding the
factors affecting patient satisfaction and motivation relating to a dental consultation. One of
these was carried out in Holland46 (-) and showed that patients who make decisions about
what is to happen to them are the most satisfied. The study also showed that patient
satisfaction was correlated to the way in which the dental professional communicated (r
=0.34 p< 0.001). In another qualitative study51 (++), it was shown that while the healthcare
system and the physical environment influenced patient satisfaction, relational aspects of
care, such as sense of connection, the dentist’s attitude, communication, and the patient’s
sense of feeling valued and empowered, were important factors in the patient’s satisfaction
with the care they receive and their relationship with the oral health promoter. In addition a
study in Sweden52 (++) showed that the credibility of the people in the dental surgery was
essential in oral health promotion, as was their ability to create confidence during a visit.
There is therefore strong evidence that positivity and communication affect patient
satisfaction and motivation.
It is likely that this evidence is applicable to UK populations as one of the studies took place
in the UK and the others in Holland and Sweden, which are culturally similar in terms of
relationships between professional and patients.
46
Schouten et al. 2003 (-)
51
Mills et al 2014 (++)
52
Ostberg 2005 (++)
Combining oral health promotion with broader health messages
Evidence Statement 11
No studies published in English since 1994 were identified which specifically examined the
effectiveness of combining oral health messages with general health promotion. One study48
(+) investigated whether dental teams would be prepared to give patients general health
advice, but no studies were identified which tested the effectiveness of combining such
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Oral Health: Approaches for general practice teams on promoting oral health
messages with oral health promotion. There is therefore no evidence on which to base
conclusions or recommendations about doing so.
48
Dyer et al. 2006 (+)
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Oral Health: Approaches for general practice teams on promoting oral health
List of abbreviations and Glossary
Caries
tooth decay (largely a disease of childhood, caries
studies are invariably carried out in children)
Caries increment
amount of new decay occurring within a given time
period
CDSS
Communication in Dental Setting Scale
DHE
dental health education
DMFT(s)
decayed, missing and filled secondary teeth
(surfaces)
Dmft(s)
decayed, missing and filled primary teeth (surfaces)
ECC
early childhood caries
F
fluoride
Frankl Score
a method of scoring behaviour in the dental surgery
GBI
Gingival Bleeding Index
GDPs
General Dental Practitioners
GI
gingival index
Gingival disease/gingivitis
inflammation of the gums
Interproximal/Approximal
cleaning
cleaning the surfaces of the teeth which are in
contact with each other
Interproximal/Approximal
surfaces
the surfaces of the teeth which are in contact with
each other
NNT
numbers needed to treat
NSPT
non-surgical periodontal treatment
OHP
oral health promotion
PCC
person-centred care
PCDs
professionals complementary to dentistry
PDA
personal digital assistant
Periodontal disease
loss of attachment of the tooth to the gum (studies
are almost ubiquitously carried out in adults)
PHP
patient hygiene performance index (method of
measuring how clean the teeth are)
PI
periodontal index
PIL
patient information leaflet
PLI
plaque index
S. mutans
Streptococcus mutans (bacteria mostly associated
with caries)
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Oral Health: Approaches for general practice teams on promoting oral health
1. Introduction
1.1
The Need for Guidance
Although people’s oral health in England has improved significantly over recent
decades there is considerable room for improvement. The Adult dental health survey
2009 (Health and Social Care Information Centre 2011) reports that the proportion of
adults in England without natural teeth has dropped from 28% to 6% in the past 30
years. In 2003, 47% of children aged 12 and 49% of young people aged 15 had
fillings. This compares with 60% and 63% respectively in 1993 (Child dental health
survey 2003 Health and Social Care Information Centre 2005). However, tooth decay
(dental caries) and gum (periodontal) disease remain widespread, despite being
largely preventable (Levine and Stillman-Lowe 2009). The Adult dental health survey
2009) found that just under 31% of adults had obvious tooth decay. In 2012, 27.9%
of children aged 5 had tooth decay (National Dental Epidemiology Programme for
England, 2012. In addition, oral cancer is one of the UK’s fastest growing cancers
(Cancer incidence in the UK in 2011, Cancer Research UK 2014).
Oral health is important to general health and wellbeing. Poor oral health can be
painful and can affect people’s ability to eat, speak and socialise normally (Dental
quality and outcomes framework DH 2011). It can lead to absences from school and
workplaces. It can also affect the ability of children to learn, thrive and develop (Local
authorities improving oral health: commissioning better oral health for children and
young people – an evidence informed toolkit for local authorities Public Health
England 2014). Left unchecked, gum disease may increase people’s risk of heart
disease and heart attacks, stroke, diabetes (and its management), as well as
rheumatoid arthritis . In addition, it can be expensive to treat. Each year the NHS in
England spends around £3.4 billion on primary and secondary dental services
(Improving dental care and oral health – call to action NHS England 2014).
Wide variations in oral health exist across England. For example, the prevalence of
tooth decay among children aged five ranges from 12.5% in Brighton and Hove to
53.2% in Leicester (National Dental Epidemiology Programme for England, 2012).
Factors associated with severe tooth decay include:

living in a deprived area

being from a lower socioeconomic group or living with a family in receipt of
income support

belonging to a family of Asian origin

living with a Muslim family in which the mother speaks little English (Rayner et
al. 2003), or

having a chronic medical condition (Department of Health, 2007).
The prevalence of certain types of oral disease is also known to be higher among
some black and minority ethnic groups (Oral health and access to dental services for
people from black and minority ethnic groups Race Equality Foundation 2013).
However the relationship between ethnicity and oral health is complex.
NHS dental services have over a million contacts with patients each week (Improving
dental care and oral health – call to action NHS England 2014). In 2009, 76% of
1
Oral Health: Approaches for general practice teams on promoting oral health
adults reported attending the dentist in the past 2 years (Adult dental health survey
2009). In 2013, 69.1% of children in England (aged under 18 years) had seen an
NHS dentist in the past 2 years (NHS dental statistics for England 2012–13 Health
and Social Care Information Centre 2013). So dental teams are ideally placed to
advise on modifiable risk factors and self-care approaches that can help prevent
many chronic non-communicable diseases – including oral health disease. (Risk
factors include tobacco use, alcohol consumption and a poor diet.) However, in the
Adult dental health survey 2009 only 9% of adults with teeth and 7% of adults without
teeth recalled being asked about smoking (Health and Social Care Information
Centre 2011). Similarly, 64% of adults in the survey did not recall being asked about
their diet by the dental team.
Reforms to the NHS dental contract look set to focus more on preventing poor oral
health, as dental teams become responsible for improving the general health of their
patients (Public Health England 2014). The Adult dental health survey 2009 found
that 78% of adults recalled being given advice at the dentist on cleaning their teeth or
gums. And 75% of adults with natural teeth in England reported that they brush their
teeth at least twice a day (76% using high or medium strength fluoride toothpaste).
However, 66% of adults surveyed had plaque on at least 1 tooth and 68% had tartar
(hardened dental plaque) in at least 1 sextant of the dental arch (Adult dental health
survey 2009). In addition, 37% of people who regularly go to the dentist said they do
not use oral hygiene products such as dental floss and interspace brushes.
According to the Adult dental health survey 2009 91% of those surveyed felt that the
dentist they saw most recently listened carefully to them. Most (89%) felt they were
given enough time to discuss their oral health and were involved in decisions about
their care or treatment. And most (94%) understood the answers they received.
However, 20% were not satisfied with the dentist. Those with a poor relationship with
the dentist tend to rate their own oral health lower, leave longer intervals between
visits to the dentist and are more likely to be extremely anxious about visiting a
dentist
1.2
The Scope of the Review
The scope of the review is defined below:
1.2.1
Areas covered by the Review
The review considered any oral health promotion message that fits the description
given in ‘delivering better oral health: an evidence-based toolkit for prevention’ (DoH,
2009). In particular it focusses any research which might inform practices how dental
teams can most effectively convey the “advice for patients” messages recommended
in that publication, regardless of the study design. This includes how to deliver these
messages in a way that ensures that when people leave the dentist, they are
satisfied about their visit and motivated to follow the advice. It also includes the
following approaches and activities:
2
Oral Health: Approaches for general practice teams on promoting oral health
1.2.2

verbal information (planned or as the opportunity arises), for example brief or very
brief advice, giving information on useful resources, and motivational interviewing
(helping motivate people to change their behaviour)

practical demonstrations, for example, showing how to remove dental plaque and
how to brush teeth properly

leaflets, posters, and other printed information. This includes different
presentations (for example, visual and numeric formats) and different writing
styles (for example, personal accounts and scientific facts)

new media, including websites and social media, email and text messaging
Population Groups Covered
The populations covered in this review are all adult and child patients who visit, or will
potentially visit a general dental practice.
1.2.3
Outcomes
We constructed a logic model (Figure 1) in order to help refine the questions. This
model is our representation of our theory of the changes we are interested in, not
necessarily what is really happening. It includes process indicators (shown in white)
and expected outcomes (shown in pink).
Health-related outcomes:

Changes in dental patients’ quality of life, including their social and emotional
wellbeing.
Oral Health –related outcomes:

Changes in the oral health of people attending dentists. E.g. levels of tooth decay,
gingivitis and periodontitis (gum disease), oral cancer, and dental trauma.
Knowledge, attitudes and behaviours:

Changes in dental health teams’ knowledge, ability, intentions and practice in
relation to promoting their patients’ oral health.

Changes in people’s experience of visiting the dentist.

Changes in people’s knowledge and ability to improve and protect their oral
health.

Changes in people’s oral health related behaviours (oral hygiene, diet, etc.)

Changes in people’s attitudes to oral health and related behaviour
3
Oral Health: Approaches for general practice teams on promoting oral health
Cognitions,
Emotions and
Knowledge
Behaviour
Change
Oral Health
Outcomes
Health
Outcomes
Oral Health
Promotion
Messages
Experience
s of visiting
the dentist
Change in
oral health
behaviour
Change in
quality of
life
Health
Promotion
Messages
including Oral
health ones
Knowledge
and
abilities
Changes in
dietary
behaviour
Change in
oral health
related
quality of
life
Interventions
Changes in
Dental teams’
Knowledge,
Abilities,
Intentions,
and Practice
Attitudes
towards
visiting the
dentist
Change in
levels of
dental
caries
Change in
social and
emotional
well being
Change in
levels of
periodontal
disease
Change in
levels of
Oral
cancer
Change in
levels of
dental
trauma
= Interventions
= Outcomes
Figure 1. Logic model: Interventions with process indicators and expected
outcomes
1.2.4
Research Questions
We considered the following specific questions in order to understand the factors affecting
the effectiveness of oral health promotion interventions (Table 1 outlines the PICO structure
for this set of questions):

Does the application of behavioural and psychological theory to oral health
behaviour lead to effective oral health promotion interventions?

What is the most effective mode of delivery (channel) of oral health promotion?

o
Is verbal delivery of oral health promotion effective?
o
Is delivery of oral health promotion by leaflet/written material effective?
o
Is delivery of oral health messages by means other than verbally / in
writing effective?
What is the content of oral health messages and how does content influence
effectiveness?
4
Oral Health: Approaches for general practice teams on promoting oral health

What is the influence of ‘receiver’ characteristics on the effectiveness of oral
health promotion?

What influence do ‘sender’ characteristics have on the effectiveness of oral
health promotion?

What influence does framing have on the effectiveness of oral health
promotion messages?

What are the barriers and facilitators to effective oral health promotion?

What factors affect patient satisfaction and motivation after a dental visit?

Are oral health promotion messages more likely to have an effect on patients
if they are linked to wider health outcomes?
5
Oral Health: Approaches for general practice teams on promoting oral health
Table 1. PICO structure for the review
P (Population)
Receiver of the message: Adult and children attending the dentist
Delivery of the message: Dental Staff
I
(Intervention)
and
Oral Health Promotion Messages. Based on the sub-question, they will be categorised in the following groups:
a) Models of behavioural change(different approaches against each other or against standard practice)
b) Presentation of the health messages (different messages against each other)
C
(Comparison)
c) The personnel involved in delivery and receipt of messages (different types of people/team members)
d) Framing of the health messages (different approaches against each other)
e) Oral Health specific messages versus Oral Health Messages along with wider health messages
O (Outcomes)
Outlined in section 4.3
In addition to this, we considered the following questions to understand the underlying mechanisms that result in some interventions
working for certain groups in certain conditions (Table 2 outlines the SPICE structure for these questions):

What are the barriers and facilitators to effective oral health promotion?

What factors affect patients’ satisfaction and motivation after a dental visit?
6
Oral Health: Approaches for general practice teams on promoting oral health
Table 2. SPICE structure for exploratory questions
S Setting
Any setting in which the oral health promotion message is conveyed to potential dental patients
P Perspective
Patients or Members of Public and/or Dental Staff or staff who are not dentally trained e.g. receptionists,
practice managers etc.
I Intervention/Interest
Oral Health Promotion Messages. Based on the sub-question, they will be categorized in the following groups:
and
a) Mode of delivery (different behavioural models against each other)
C Comparison
b) Presentation of the health messages (different messages against each other)
c) The people involved in delivery and receipt
d) Framing of the health messages (different approaches against each other)
e) Combining oral health with wider health issues
E Evaluation
Barriers and Facilitators in designing the messages
Barriers and Facilitators in delivering the messages
Acceptability of the Messages
Patient Experience
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Oral Health: Approaches for general practice teams on promoting oral health
2. Methodology
2.1
Literature Search
This review considered studies in general dental practice that looked at different
ways of promoting good oral health in adult and child patients, both in terms of
awareness and in terms of health related behaviours, and health outcomes. Oral
health awareness encompasses knowledge of lifestyle impact and diet as well as oral
hygiene practices. An approach was therefore used that included all of these aspects
of oral health.
It was important that the studies were restricted to messages which could potentially
be conveyed in the context of general dental practice. The strategy was used to
narrow results as far as possible without missing potentially relevant studies. Also, in
order to ensure studies retrieved from the searches fulfilled the inclusion criteria, the
search specified study designs, using a mixture of MeSh terms and textwords.
Appendix A provides the full search strategy developed for OVID Medline.
The cut-off date for publication of evidence was 1994. This date was chosen as the
last landmark review in this area was conducted by Kay and Locker (1998), which
included papers published up until 1994. It was felt that the search should not be
limited by country because oral health promotion is universal.
Oral health studies are published in all types of medical, psychological and
sociological journals. Therefore, it was felt that a large number of databases covering
all of those areas should be searched in order to gather the broadest range of
evidence possible. Search strategies were devised to search the following database
catalogues of literature:

AMED (EBSCO)

CINAHL (EBSCO)

Cochrane Library (which includes the Cochrane Database of Systematic Reviews,
Database of Abstracts of Reviews of Effect (DARE), Cochrane Central Register
of Controlled Trials (CENTRAL), Cochrane Methodology Register (CMR), Health
Technology Assessment Database (HTAD) and NHS Economic Evaluation
Database (NHSEED) – we used the Wiley Online Library platform to conduct the
Cochrane Library search

EMBASE (Elsevier)

Medline (EBSCO)

Medline (OVID)

Medline (PubMed)

Medline in Process (OVID)

PsycINFO

PsycARTICLES

ScienceDirect (Elsevier)

SocINDEX (EBSCO)
8
Oral Health: Approaches for general practice teams on promoting oral health

ASSIA

Social Policy and Practice

HMIC (Health Management Information Consortium)

Cochrane Oral Health Group
In addition, the following grey literature databases were also searched:

The Knowledge Network

Intute

MedNar

Copac

EPPI-Centre

EThOS

OpenGrey

TRIP
If sufficient results had not been retrieved from these searches, further websites (as
detailed in the protocol) would have been searched. However, as the primary
searches resulted in a large number of articles, a further search was not carried out.
2.2
Call for Evidence
We also used our professional networks and contacts, including the British Dental
Association, to issue a ‘Call for Evidence’ in order to ensure that any current or
recently completed relevant research would be included in the review. Four
potentially relevant pieces were sent to us, of which one article was included in the
final review.
2.3
Citation checking
In order that no studies were overlooked, we checked the citations of three
systematic reviews. The Cochrane Library was searched for relevant reviews
pertaining to oral health promotion. Only two Cochrane reviews were identified as
being relevant (Khokhar, 2001; and Harris 2012). In addition, after consultation with
the CPH team, a non-Cochrane systematic review was also identified (Yevlahova
and Satur, 2009). The reference lists for all three reviews were cross-checked with
the results from our original search. Only one study was found which was in scope,
but had not been detected by our search. This study was then subjected to the
procedure outlined below and included in the review.
9
Oral Health: Approaches for general practice teams on promoting oral health
2.4
Selection of Studies for Inclusion
Inclusion criteria for the effectiveness questions:

Any paper incorporating the PICO structure as outlined in Table 1.

Any intervention or observational study
Inclusion criteria for the exploratory questions:

Any paper incorporating the SPICE structure as outlined in Table 2.

Any study that used qualitative study designs such as ethnographic research,
case studies, process evaluations and mixed methods designs.
Exclusion criteria:
2.5

The evidence base underpinning oral health advice for patients

Clinical dental treatment

Approaches to tackling clinical diagnoses of dental anxiety and phobia (as
listed as one of the specific phobias in the Diagnostic and Statistical Manual
of Mental Disorders [DSM-V]).

Oral health needs assessments

Community-based oral health promotion programmes and interventions

Oral health promotion and dental treatment in residential or care settings
(including hospitals and nursing and residential care homes for children,
young people and adults).

Any article other than primary research

Articles outlining expert opinions

Any paper published before 1994
Selection Process
Duplicates were removed from the retrieved search results. After training and
calibration, three reviewers screened the titles and abstracts for obviously irrelevant
studies and these were excluded. Studies were then reviewed by the team’s content
experts who removed studies which did not specifically fit the inclusion and exclusion
criteria. Where there was insufficient data in the title or abstract, or both, to make a
clear decision regarding eligibility of studies, the full text of the paper was obtained.
Details of excluded studies at both stages have been documented.
10
Oral Health: Approaches for general practice teams on promoting oral health
Once the titles and abstracts had been screened, the full texts were obtained for
remaining articles. All papers were then independently assessed for appropriateness
to the review’s aims by two reviewers. Where there were discrepancies in the final
decision of whether the article was to be included or excluded, a third reviewer was
consulted in order to reach a consensus. All details of inclusion and exclusion at this
stage have been documented in an audit trail.
2.6
Search Results
Figure 2 illustrates the flow of studies through the sifting process. References were
managed using EndNote; where databases were not compatible with Endnote,
search results were recorded in Microsoft Excel. Appendix C summarises all of the
full papers which were excluded from the review, with corresponding reasons for
exclusion.
Figure 2. Flow of studies
Search results
N = 5,895
Screening for titles and
abstracts
Full text screening
Excluded N = 5,735
Total Excluded N = 108
N = 160
Included in final review
N = 52
2.7
Quality Appraisal
The internal and external validity of all the included studies (both quantitative and
qualitative) were assessed by the quality appraisal checklists provided in Methods
for the development of NICE public health guidance (third edition). Examples of the
11
Oral Health: Approaches for general practice teams on promoting oral health
quality assessment checklists used for different study designs can be found in
Appendix B. Each study was rated (++, + or -) to denote its quality. Efficiency and
effectiveness were considered key to the quality assessments. Our methodology
expert (MN) provided an in-depth training session where the four researchers
worked through examples of the quality assessments to ensure consensus on what
was required. The quality assessments for each of the included papers were then
conducted individually by the researchers, but in the same room to allow for
discussion about any difficult or contentious judgements, in order that a consensus
was reached. An additional reviewer independently assessed 10% of the quality
assessments for the second time to ensure consistency. Following this, where there
were reporting issues, where articles did not provide sufficient information to make
judgments, the quality assessments were checked again by two reviewers until
agreement was reached.
2.8
Study categorisation
Studies were categorised by design as well as the research question that they
related to.
2.9
Assessing applicability
The evidence tables were each assessed at the synthesis stage, for their applicability
to providing guidance on oral health promotion approaches for dental health teams.
The underpinning studies for each statement were assessed as a collective with
regards to their population(s), setting(s), intervention(s), and outcome(s), and the
overall similarity they have to the original research questions outlined. Once
conclusions had been drawn from the collective evidence, the resultant evidence
statement was categorised as:

Directly applicable

Partially applicable

Not applicable
An additional statement accompanied each evidence statement detailing the
applicability category to which it was assigned, as well as the reasons why this
category was allocated.
2.10
Synthesis
The studies were grouped using the following methodology. Members of the research
team discussed and decided for each study which of the research questions was the
research’s primary and secondary focus. A content expert then read and considered
the key findings of each paper. The key findings were compared and contrasted and
key themes identified. No meta-analysis was carried out due to the heterogeneity of
both interventions and outcome measures. For the qualitative papers, thematic
analysis of content was undertaken by two content experts, revealing emergent
themes within and across groups of papers.
12
Oral Health: Approaches for general practice teams on promoting oral health
2.11
Strength of the evidence
Evidence supporting the findings was considered to be strong if it was supported by
data from one or more studies rated (++), OR more than one RCT rated (+) or better.
Evidence was considered moderate if there was supportive information from more
than one study of any design which was rated (+) or better. Evidence was considered
weak if the finding was supported by the results of studies rated (-).
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Oral Health: Approaches for general practice teams on promoting oral health
3. Summary of Findings
3.1 Overall summary of studies identified
In the main review, 44 studies reported in 52 papers were included. Fifteen of the studies
were RCTs, two were cluster RCTs, and one was a controlled trial. Also included were five
quasi-experimental studies, two before-and-after studies without control groups, three
surveys, eleven qualitative studies, three mixed methods studies, one audit and one pilot
study.
Two of the RCTS were high quality (++), ten were rated as moderate quality (+) and three
were rated (-). Both cluster RCTs were of moderate quality (+) and the controlled trial was
rated (-). Of the qualitative studies, three were appraised as high quality (++) and the
remaining eleven (which includes the qualitative parts of the three mixed methods studies)
were appraised as moderate quality (+). The before and after studies, quasi-experimental,
audit, pilot and survey studies were all rated (-) apart from one quasi-experimental study
which was high quality (++), and one survey which was methodologically sound (+).
The evidence was very disparate and the quality of reporting highly variable. Many studies
relied on patient reported behaviour rather than objective clinical measures or observed
behaviours. Many had short follow up periods. Similarly, it was not possible to undertake any
meta-analyses, as the homogeneity of neither the interventions or outcomes were
insufficient, or the outcomes were measured in units that could not be translated into
behavioural or health outcomes. Graphical representation of the findings was therefore
considered inappropriate.
The heterogeneity of the populations studied, the settings, and the outcomes measured in
the reviewed studies did not allow overall definitive conclusions to be drawn regarding the
“best” way to deliver oral health promotion. Therefore careful consideration was given to
determining how best to group the studies in order to provide meaningful evidence
statements that would guide the development of recommendations.
Our search strategy revealed a considerable number of studies focusing on the delivery of
smoking cessation advice. The majority of the smoking cessation studies identified were not
specifically about promoting oral health per se. It was therefore decided, in consultation with
the CPH team, that while we would endeavour to undertake a brief narrative synthesis in
order to be able to make a ‘state-of–the-art’ statement about smoking cessation advice via
dental surgeries, this would not be part of the main review. Appendix D provides an overview
of the smoking cessation studies.
14
Oral Health: Approaches for general practice teams on promoting oral health
Table 1. Summary of included studies
Research Question
No of studies
Quality of studies
3.2 Does the application of behavioural and psychological theory to oral health behaviour lead to effective oral
health promotion interventions
8
3.3.1 Is verbal delivery of oral health promotion an effective mode of delivery?
8
3.3.2 Is delivery of oral health promotion by leaflet / written material effective?
7
3.3.3 Is delivery of oral health promotion by means other than verbal / leaflet effective?
3
3.4 What is the general content of oral health messages and how does the content affect effectiveness?
6
3.5 How do ‘receiver’ characteristics affect the effectiveness of oral health promotion?
6
3.6 How do ‘sender’ characteristics affect the effectiveness of oral health promotion?
4
3.7 What is the affect of ‘framing’ on the effectiveness of oral health promotion messages?
3.8 What are the barriers and facilitators to effective oral health promotion?
1
11
3.9 What factors affect patient satisfaction and motivation after a dental visit?
3
3.10 Are oral health promotion messages more likely to have an effect on patients if they are linked to wider
health outcomes?
0
3++
3+
24+
46+
11+
21++
3+
24+
21++
2+
111++
9+
12++
11
N/A
1
N/A = Not applicable
15
Oral Health: Approaches for general practice teams on promoting oral health
3.2 Does the application of behavioural and psychological theory to oral health behaviour lead to effective oral health promotion
interventions?
Studies
Design
Quality
Population
Intervention
Comparison
Outcome
++
External
Validity
++
Patients with
periodontal
disease
Individually tailored
oral health
programme
Standard care
Pocketing Plaque
Gingival health
Positive
finding
No
Yes
Jonsson et al.
(2009, 2010,
2012)
(3 papers)
Sweden
Jonsson et al.
(2009)
Sweden
RCT
Quasiexperiment
al (2 cases)
-
-
Periodontal
patients
Motivational
interviewing at
treatment
Unclear
Munster Halvari
et al. (2012)
RCT
++
+
University
students
Autonomy –
supportive interview
Standard care
Plaque
Gingivitis
Pocketing
Reported behaviour
Plaque levels
Behaviour
Yes
Yes
Yes
Yes
Yes
Yes
Kakudate et al.
(2009)
RCT
+
+
Counselling with sixstep method
Twenty minutes oral
hygiene instruction
Plaque Index
Behaviour
Yes
Yes
Clarkson et al.
(2009)
UK
RCT
(individual
and cluster
analysis)
+
+
Patients with
mild /
moderate
periodontal
disease
Adults
attending
dentist
Oral hygiene
education based on
social cognitive aid
implementation
theory
Routine care and oral
hygiene advice
Plaque score
Yes (only in
cluster)
Bleeding score
Yes (only
in cluster)
RCT
-
OH in group or
individual
Usual dental treatment
Reported behaviour
Plaque scores
Pocket depth
Behaviour
Yes
Yes
Yes
Yes
Little et al. (1997)
++
Patients with
periodontal
disease
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Oral Health: Approaches for general practice teams on promoting oral health
Fjellstrom et al.
(2010)
Quasiexperiment
al
++
-
Healthy
students
Cognitive Behaviour
and Oral Health
promotion
Traditional education
and pictures of
periodontal disease
Kasila et al.
(2006, 2008) (2
papers)
Qualitative
+
+
School
children
Transtheoretical
behaviour change
counselling
Not applicable
2
Gingival health
Plaque index
Knowledge
Behaviour
Readiness for change
Reported behaviour
NR
2
N/A
NR = Not reported
17
Oral Health: Approaches for general practice teams on promoting oral health
This section examines the evidence concerning oral health promotion interventions
which include an active component that is based on behaviour change theory or the
psychology of individual choice. The studies in this section were generally of higher
quality than in other sections. The evidence for this section included eight studies
reported in eleven papers.
A randomised controlled trial, published in two papers1,2 (++), of an individually tailored
oral health educational programme, based on a cognitive behavioural approach, involved
113 adult patients (60 females and 53 males) with chronic periodontitis, who were
randomly allocated to an experimental or a control group. The intervention group
received an individually tailored oral health educational programme based on cognitive
behavioural principles. The individual tailoring for each participant was based on
participants' thoughts, intermediate, and long-term goals, and oral health status. The
control group (n=56) received standard periodontal care with demonstrations of oral
hygiene and structured information. The effect of the programme on gingivitis [gingival
index (GI)], oral hygiene [plaque indices (PLI) and self-report], and participants' global
rating of treatment was evaluated three and 12 months after oral health education and
non-surgical treatment. Between baseline and the 12-month follow-up, both GI and PLI
improved more in the experimental group than in the control group. The mean gain-score
difference was 0.27 for global GI [99.2% confidence interval (CI): 0.16–0.39, p<0.001]
and 0.40 for proximal GI (99.2% CI: 0.27–0.53, p<0.001). The mean gain-score
difference was 0.16 for global PLI (99.2% CI: 0.03–0.30, p=0.001), and 0.26 for proximal
PLI (99.2% CI: 0.10–0.43, p<0.001). The participants in the intervention group reported a
higher frequency of daily inter-dental cleaning and were more certain that they could
maintain the attained level of behaviour change. The individually tailored oral health
educational programme was efficacious in improving adherence to oral hygiene for a
year. The largest difference was for interproximal surfaces. A further paper based on the
same study was published3 which included the effect on treatment as an outcome
measure. This paper indicated that patients in the theory based intervention were
regarded as achieving treatment success, or had higher odds of treatment success.
Jonsson also published results of a quasi-experimental study4 (-) which assessed the
effect of an individually tailored treatment programme for improved oral hygiene. Two
experimental single-case studies with a multiple-baseline design were carried out in
Sweden in a periodontal referral clinic. Different self-administered oral hygiene
behaviours (toothbrushing and interdental cleaning) were examined. Cognitive
Behavioural techniques were used to organise the strategies for the intervention. The
central features in the programme were the individual analysis of knowledge and oral
hygiene habits, with the patients setting goals for oral hygiene behaviour. Plaque,
bleeding on probing, and periodontal pocket depth were all reduced and the positive
results remained stable throughout the two year study period. The authors concluded
that the successful application of this educational model suggests that it could be used
as a method for tailoring interventions targeted at oral hygiene for patients with
periodontal conditions.
A randomised controlled trial5 (++) tested the hypotheses that a dental intervention
designed to promote dental care competence in an autonomy-supportive way, relative to
standard care, would positively predict patient motivation increases in dental home care,
perceived dental competence, and dental behaviours. It was also hypothesised that the
18
Oral Health: Approaches for general practice teams on promoting oral health
intervention would decrease both dental plaque and gingivitis over 5.5 months. The
study tested the hypothesis that the self-determination model within the intervention
would increase motivation and perceived dental competence, both of which would be
associated with improvements in dental behaviour, which would, in turn, lead to
decreased plaque and gingivitis. A randomised two-group experiment was conducted at
a dental clinic with 141 patients (M age = 23.31 years, SD = 3.5), with pre- and postmeasures (after 5.5 months) of motivation variables, dental behaviours, dental plaque,
and gingivitis. The intervention made a moderate difference to dental behaviour, but
autonomous motivation for the project and perceived competence, perceived autonomy
support, dental plaque, and gingivitis all improved considerably. A structural equation
model supported the hypothesised process model. Considering the very large effects on
reductions in dental plaque and gingivitis, promoting dental care competence in an
autonomy-supportive way, relative to standard care, has important practical implications
for dental treatment, home care, and oral health.
A study by Kakudate et al.6 (+) sought to determine whether a six-step behavioural
cognitive method is more effective than traditional oral hygiene instruction. Thirty-eight
adult patients with chronic periodontitis were randomly assigned to two groups. The
intervention group received counselling by Farquhar’s six-step method for ten minutes
after traditional oral hygiene instruction. In both groups, oral hygiene instruction was
given once a week, and performed three times in total for three weeks. The control group
was given traditional oral hygiene instruction for 20 minutes. Clinical characteristics,
deposition of dental plaque, frequency and duration of brushing, frequency of interdental
cleaning and scores based on a scale of “self-efficacy for brushing of the teeth” were
compared in both groups. There were no differences between the two groups in clinical,
demographic, behavioural and self-efficacy characteristics at the baseline examination.
However after the third visit, the intervention group had significantly higher self-efficacy,
lower plaque index scores, longer brushing duration and higher frequency of inter-dental
cleaning than those of the control group. Multiple regression analysis showed significant
association of tooth brushing duration with self-efficacy for brushing of the teeth
(p < 0.001). There is therefore evidence that the six-step method is more effective for
enhancing self-efficacy and behavioural change in oral hygiene than traditional oral
hygiene instruction alone.
A cluster randomised controlled trial7 (+) tested the hypothesis that an evidence-based
intervention, framed within psychological theory, would improve patients' oral hygiene
behaviour. The impact of the trial methodology on trial outcomes was also explored by
conducting two independent trials, one randomised by patient and one by dentist. The
study included 87 dental practices and 778 patients (Patient RCT = 37 dentists/300
patients; Cluster RCT = 50 dentists/478 patients). Controlling for baseline differences,
pooled results showed that patients who experienced the intervention had better
behavioural (timing, duration, method), cognitive (confidence, planning), and clinical
(plaque, gingival bleeding) outcomes. However, clinical outcomes were significantly
better only in the Cluster RCT, suggesting that the impact of trial design on results needs
to be explored further.
A randomised clinical trial8 (-) assessed the effect of a behaviour modification
intervention on oral hygiene skills, adherence and clinical outcomes for older periodontal
patients. Participants (n= 107) were aged 50-70 with moderate periodontal disease. They
19
Oral Health: Approaches for general practice teams on promoting oral health
were randomly assigned to usual care or intervention. The intervention consisted of five
weekly, 90-mm sessions that included skill training, self-monitoring, weekly feedback
about bleeding points and group support focused on long-term habit change. For the
control group, usual care was given which consisted of standard periodontal
maintenance and recall. Four-month follow-ups indicated significant improvements in the
intervention versus the control group for oral hygiene skills and self-reported flossing (p
<0.001), plaque, gingival bleeding, bleeding upon probing throughout the mouth, and
pocket depth that measured between 3mm and 6mm at baseline (p<0.009). Applying the
principles of behavioural self-management (similar to autonomy support) offers an
effective and relatively inexpensive means of helping patients improve their self-care
skills and achieve high levels of adherence to an effective self-care regimen.
A study9 (++) compared a modified Cognitive Behavioural Therapy (CBT) model to
traditional oral hygiene instruction in order to determine the impact on increased
adherence to oral hygiene. Tools developed and tested in this pilot study were a selfreporting questionnaire, visual information consisting of pictures, and a diary to
document their thoughts and feelings prior to and during tooth cleaning, according to the
modified CBT method. Four participants were divided into two groups; CBT and control
group. At the first visit, all participants answered a self-reporting questionnaire. The
clinical examination consisted of measuring the PI, GI and GBI. The same information
and instructions were given. All received toothbrushes, dental floss and professional
tooth cleaning. The CBT group was instructed to document their feelings and thoughts in
a diary. After three weeks, the participants answered the same questionnaire, and the
same clinical measurements were conducted at the re-examination. The CBT group
brought their diaries for evaluation. At the end of the study, there was a difference in PI,
GI and GBI between the groups. The levels of PI, GI and GBI had decreased more in the
CBT group than in the control group but no p-values or statistics were given. The
questionnaire also showed that the CBT group had increased their knowledge and
awareness about oral health. This pilot study shows that using a modified model of CBT,
by keeping a diary, resulted in increased adherence to oral hygiene and knowledge
about gingivitis, compared with traditional instructions
The effectiveness of oral health counselling concerning changes of oral hygiene habits in
11- to 13-year-old schoolchildren within a theoretical framework of the transtheoretical
model and the motivational interview was tested in one study, published in two
papers10,11 (+). Thirty-one (n=31) schoolchildren were included in the counselling
sessions that were conducted by four dental hygienists. The audiotaped and transcribed
data were analysed qualitatively by using content analysis. In 2002, nearly every
schoolchild needed to establish changes in oral hygiene habits but the assessment of
schoolchildren's readiness for change often remained unclear. In 2002, giving normative
advice was the most commonly used counselling strategy when addressing the need for
change, but dental hygienist-centred change discussion and goal setting were also
apparent and were related to the schoolchildren's rarely manifested changes of oral
hygiene habits after the period of a year. The results suggested that the transtheoretical
framework might be useful in constructing oral hygiene counselling for schoolchildren
which focuses on the personal dynamics of change.
20
Oral Health: Approaches for general practice teams on promoting oral health
Summary and Evidence Statement
A number of high quality RCTs of interventions based on theoretical behavioural or
psychological models have shown the interventions to be successful at changing
individuals’ behaviour in a way that positively benefits their oral health, in terms of oral
hygiene and gingival health. However none of the studies showed an effect on caries
levels, unless fluoride application was involved.
Evidence Statement 1
There is strong evidence from five RCTs reported in seven papers (2++, 2 +, 1-)1,2,3,5,6,7,8, two
quasi experimental studies4,9 (1++, 1-), and one qualitative study published in two papers10,11
(+) to suggest that the use of behavioural and psychological theoretical models in the
development of oral health promotion interventions, results in improved oral hygiene and
gingival/periodontal health. One randomised controlled trial1-3 (++) testing an oral health
promotion programme based on a cognitive behavioural approach, showed a mean gain
score difference of 0.27 for the Gingival Index in the intervention group (99.2% confidence
interval (0.16) – (0.39), p<0.001). Another RCT5 (++) which tested an intervention based on
an autonomy-supportive approach also showed significant effects on plaque reduction
(effect size -0.86, 95% confidence interval (0.81) – (0.91)) and gingivitis (effect size -1.21,
95% confidence interval (-1.18) – (1.24)). Changes in positive behaviour were also reported
in a quasi-experimental study investigating the role of cognitive behavioural therapy9 (++)
and a qualitative study applying the transtheoretical model of behaviour change10-11 (+).
These studies did not show changes in objectively measured dental health.
This evidence is applicable to people in the UK because all of the studies were conducted in
circumstances which prevail in the UK and the models used to develop the interventions are
apposite to UK populations.
1,2,3
Jonsson et al. 2009, 2012, 2010 (++)
4
Jonsson et al. 2009 (-)
5
Munster Halvari et al. 2012 (++)
6
Kakudate et al. 2009 (+)
7
Clarkson et al. 2009 (+)
8
Little et al. 1997 (-)
9
Fjellstrom et al. 2010 (++)
10
Kasila et al. 2006 (+)
11
Kasila et al. 2008 (+)
21
Oral Health: Approaches for general practice teams on promoting oral health
3.3 What is the most effective mode of delivery (channel) of oral health promotion?
Eighteen studies examined oral health promotion delivered in a variety of different ways (ten
were randomised controlled trials, two were cluster randomised controlled trials, two were
quasi- experimental studies, one was a before and after study without a control group, one
was qualitative, one was an audit and one was a pilot study). The studies varied in quality
and there was heterogeneity in the populations and outcomes evaluated. Most importantly
they examined the effectiveness of oral health promotion delivered in a variety of different
ways. We have therefore formed three sub groups: the first is effectiveness of oral health
promotion delivered verbally by dental health professionals; the second is the effectiveness
of OHP (oral health promotion) using leaflets/written material and the third is the
effectiveness of oral health promotion delivered in modes other than by verbal advice or
leaflets.
Research Questions:
3.3.1
Is verbal delivery of oral health promotion messages by oral health
professionals effective?
3.3.2
Is delivery of oral health promotion by leaflet/written material effective?
3.3.3
Is delivery of oral health promotion by means other than leaflet/written material
effective?
22
Oral Health: Approaches for general practice teams on promoting oral health
3.3.1 Is verbal delivery of oral health promotion messages by oral health professionals effective?
Study
Design
Quality
Validity
Population
Intervention(s)
Comparison(s)
Outcome(s)
Blinkhorn et al.
(2003)
Cluster RCT
+
+
Dental health
counselling by hygienist
Toothbrush and paste
Dmft/s
Hausen et al.
(2007)
Finland
RCT
+
+
Attending
children and
parents
11 and 12 year
olds
Positive
findings
No
Normal care including
fluoride and oral hygiene
Dmfs
Yes
Hugoson et al.
(2003, 2007)
Sweden
Jonsson et al.
(2006)
RCT
+
++
Young adults
Dental health
counselling by hygienist
(plus toothpaste and
xylitol)
Dental prophylaxis and
oral hygiene instruction
Nil
RCT
-
+
Adults
OHP by dental hygienist
Clinical assessment only
Lepore et al.
(2011)
USA
Quasiexperimental
-
-
Paediatric
patients
Oral hygiene and diet
information by dentist
Routine advice and
topical fluoride
Weinstein et al.
(2004, 2006)
RCT
-
+
Parents of
young children
Pamphlet and video
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Jonsson et al.
(2009)
Sweden
Quasiexperimental
(2 cases)
-
-
Periodontal
patients
Motivational
interviewing, video, and
pamphlet
Motivational interviewing
at treatment
Plaque levels
Gingivitis
Repaired behaviour
Plaque levels (PI)
Gingival health
Reported behaviour
S Mutans
Plaque score
Dmft
Gingival health
Reported behaviour
New decay
dmfs
Wang et al.
(2010)
RCT
+
+
Parents of
paediatric
patients
Individualised verbal
instruction plus visual
tool
Standardised
information
Plaque
Gingivitis
Pocketing
Reported behaviour
Attendance
Child cooperation with
treatment
Yes
Yes
Yes
Yes
Yes
Yes
Unclear
23
Oral Health: Approaches for general practice teams on promoting oral health
This section examined the evidence pertaining to the effectiveness of oral health promotion
advice being given verbally by a dental health professional. Effectiveness was considered
from the point of view of (a) increases in knowledge, (b) changes in behaviour, and (c)
changes in oral health outcomes.
A study13 (+) was carried out which tested the effectiveness of dental health educators in
general dental practice. This was a two-cell, parallel group, cluster randomised, controlled
clinical trial of two years' duration. Set in 30 general dental practices in North-West England,
the participants were 269 mothers of 334 preschool children. Those in the test group were
given visits to a dental health educator over a two year period to counsel mothers of at-risk,
preschool children. The rest were held as a control. The main outcome measures were
caries prevalence of the children and dental health knowledge, attitudes and toothbrushing
skills of the parents. The statistical analysis controlled for the clustering of children within
practices. After two years, 271 (81%) children and 248 (92%) mothers remained in the study.
There was an 8% difference in the proportion of children who were plaque free between the
groups in favour of the test group children but this was not statistically significant. There was
also a difference of 0.57 dmft in favour of the test group, but again the difference was not
statistically significant. The mothers in the test group were more knowledgeable, had better
attitudes towards the dental health of their offspring, and had better toothbrushing skills than
those in the control. Each two hour session to counsel ten parents cost £40. The authors
concluded that primary care trusts should carefully consider the cost value of seconding
dental health educators to counsel parents of regularly attending, at-risk, preschool children
when considering how to utilise general dental practices to improve oral health.
Another study14 (+) investigated whether DMFS increment can be decreased among
children with active initial caries, by oral hygiene and dietary counseling, and by using
noninvasive preventive measures. Except for children with learning difficulties attending
special schools, all 11- to 12-year-olds in Pori, Finland, with at least one active initial
caries lesion, were invited to participate in the study and were then randomised into two
groups. Children in the experimental group (n = 250) were offered an individually
designed patient-centered preventive programme aimed at identifying and eliminating
factors that had led to the presence of active caries. The program included counseling
sessions with emphasis on enhancing the use of the children’s own resources in
everyday life. Toothbrushes, fluoride toothpaste, and fluoride and xylitol lozenges were
distributed to the children. They also received applications of fluoride/chlorhexidine
varnish. The children in the control group (n = 247) received basic prevention offered as
standard in the public dental clinics in Pori. For both groups, the average follow-up
period was 3.4 years. A community level program of oral health promotion was also run
in Pori throughout this period. Mean DMFS increments for the experimental and control
groups were 2.56 (95% CI 2.07, 3.05) and 4.60 (95% CI 3.99, 5.21), respectively (p <
0.0001): prevented fraction 44.3% (30.2%, 56.4%). The results show that by using a
regimen that includes multiple measures for preventing dental decay, caries increment
can be significantly reduced among caries-active children living in an area where the
overall level of caries experience is low.
Hugoson et al12 (+) examined the effect of different preventive programmes on oral hygiene.
Four hundred subjects aged 20–27 years, 211 males and 189 females, participated in the
study. They were recruited from a Public Dental Service clinic and from a private dental
practice in Jönköping, Sweden. The effect of the programmes on plaque and gingivitis was
24
Oral Health: Approaches for general practice teams on promoting oral health
evaluated over a three year period. The programmes included activities that were adapted
for individuals as well as for groups. This randomised, blinded, parallel, controlled clinical
study examined the effectiveness of four dental health programmes. In one group the
participants had traditional oral care, in the second group information about caries/gingivitis
was presented using flip charts and oral hygiene instruction was given. They also had their
teeth professionally cleaned six times per year. In a third group, no professional cleaning
was given, and in the fourth group, the programme was conducted as a group activity.
Plaque indices (PLI) and gingival indices (GI) were used to evaluate the programmes. All
programmes resulted in a decrease in PLI and GI. The greatest decrease was found in the
group that was followed-up every two months. Professional tooth cleaning was nonsignificant for the clinical result. Gingival health at baseline, participation in any of the test
programmes, and knowledge of the dental diseases caries, gingivitis or periodontitis were
significant predictors of good gingival health. The study confirms the efficacy of three
different preventive programmes in reducing supragingival plaque and gingival inflammation.
Professional tooth cleaning provided no clinical benefit beyond that derived from individual
and group-based health education.
At the ten year follow up15 (+), the individuals’ knowledge was undiminished while behaviour
concerning approximal cleaning had reduced from 90% to approximately 70% of the
individuals. A slight behavioural change concerning number of snacks was found in the
course of the study with a shift towards fewer snacks per day. The study showed that simple
prophylactic models have an effect on, and maintain, young adult individuals’ knowledge and
behaviour concerning oral health, and that new knowledge is remembered for long periods
of time, while changes in behaviour are maintained less well. Moreover, it was found that the
scope of the prophylactic programme measured in time and cost had little effect on the longterm result.
An experimental study16 (-) aimed to determine whether a “report card-like” oral health action
plan was effective in improving oral health behaviours in a sample of 69 participants aged
one to six years. Participants were divided randomly into control and intervention groups.
Patients in both groups received examination topical fluoride and professional cleaning. The
control group received routine oral hygiene instruction and diet advice. The intervention
group received the same, but in addition they also received a personalised oral health action
plan. Data collected included dmft, plaque score, Streptococcus mutans levels and oral
health behaviours. Participants in the intervention group received an oral health action plan
that included: 1. Child’s current caries-risk status; 2. Identification issues of concern; 3. One
“goal” to improve on for the next visit. All participants returned after two months for follow-up
examination and data collection. The intervention group had lower S. Mutans counts, lower
plaque scores and improved gingival health (p<0.05).
Another study17,18 (-) compared the effect of motivational interviewing counseling treatment
with that of traditional health education, on parents of young children at high risk of
developing dental caries. The authors enrolled parents of 240 infants aged six to 18 months
in the study and randomly assigned them to either a motivational interviewing intervention
group or a traditional health education (control) group. Parents in the control group received
a pamphlet and watched a video. Parents in the intervention group also received the
pamphlet and watched the video; in addition, they received a personalized counseling
session and six follow-up telephone calls. After one year, children in the intervention group
had 0.71 new carious lesions (SD = 2.8), while those in the control group had 1.91 (SD=4.8)
25
Oral Health: Approaches for general practice teams on promoting oral health
new carious lesions (t [238] = 2.37, one-tailed P <0.01). They concluded that the intervention
was a promising approach which may lead parents and others to better accept dental
recommendations about preventing caries in their children.
Jonsson et al.19 (-) reported a randomised control trial to test an intervention aiming to
encourage patients to increase their responsibility for their oral self-care. A total of 75
individuals were re-examined one to two years after their initial therapy at the Department of
Periodontology, Uppsala County Council, Sweden. Patients who exhibited insufficient
compliance (37 individuals) were included in a randomised single-blind control trial to test
the intervention. The intervention consisted of a hygienist engaging in a dialogue with the
patient which aimed to increase their feeling of empowerment. The process aims for the
patient to make decisions about their goals and how to achieve them, and the hygienist
assists the patient in the achievement of those goals. Patients were examined at baseline
and three months after the intervention. The results demonstrated that patients in the
intervention (IV) group increased their interdental cleaning and reduced their plaque index
significantly compared with the control group. The former also reduced the number of
periodontal pockets >4 mm significantly from baseline until after the hygiene treatment. The
majority of the individuals in the IV group reported that the written commitment had
influenced their oral self-care habits in a positive direction. The intervention enhanced the
client participation in the treatment process and improved the compliance and oral self-care
behaviours. It also contributed to a reduction in periodontal pockets.
A quasi-experimental study with a multiple-baseline design was carried out in Sweden4 (-) in
a periodontal referral clinic. Please see page 18 for more details.
Finally, a study examining the effect of using illustrations when educating parents about their
child's upcoming operative appointment, on parents' and their children’s' responses to the
treatment, was reported by Wang et al.20 (+). Data were collected from 189 parents of four
to ten year-old pediatric dental patients who needed operative treatment. The parents
received information about their child's upcoming operative visit in the intervention group
with the support of standardised illustrations (flip chart), and/or individualised drawings.
Parents and providers responded to surveys following the operative appointments.
Behaviour ratings were assessed on a scale of 1 (definitely negative) to 4 (definitely positive).
The data showed that parents in the intervention group felt that the information was more
helpful than the parents in the control group felt (control group satisfaction score = 3.8,
intervention group satisfaction score = 4.18, p<0.05). Parents who were informed only
verbally were more likely to (a) miss the operative appointment (47% vs 19%/16%/10%;
p<0.001) and (b) remain in the operatory during treatment (47% vs 18%/26%/19%; p<0.01)
than parents who received standardised illustrations, individualised illustrations, or both
illustrations respectively. Patients/children whose parents had received verbal information,
compared to those parents who had received any form of illustrative information, behaved
more negatively during appointments (Frankl score 3.30 vs 3.54 p=0.04). The authors
concluded that educating parents about the basic disease process of dental caries with the
aid of illustrations increased parents' cooperation with the recommended dental treatment for
their children and improved their children's behaviour during the treatment.
Summary and Evidence Statement
The key finding is therefore that patient/parent knowledge and behaviour (including oral
hygiene) is improved by the giving of advice/instruction by a dental professional. However
there is no substantial evidence that oral health promoting advice reduces caries unless
26
Oral Health: Approaches for general practice teams on promoting oral health
fluoride is provided (in toothpaste, varnish, rinse or tablets). The data supporting this
conclusion includes three RCTs (+), one cluster RCT (+), two low quality RCTs (2-), and two
quasi-experimental studies (2-). The evidence supporting our conclusions should be
considered strong.
Evidence Statement 2
Two RCTs (reported in three papers) carried out in Sweden and Finland12,15,19 (1+, 1-)
showed that oral health promotion delivered verbally by dental health professionals improved
adult and child patients’ knowledge levels, and reported behaviours. However a cluster RCT
in the UK involving young children13 (+) failed to demonstrate that advice from an oral health
educator improved caries (dmf intervention = 2.65 (SD 2.5), dmf control = 3.22 (SD 2.85)) or
that it improved knowledge to a statistically significant extent (intervention score = 47, control
= 39). One RCT14 (+), in which fluoride toothpaste was also distributed, demonstrated a
reduction in caries increments (DMFS increments in intervention 2.56 (confidence interval
(2.07) – (3.05)), control 4.60 (confidence interval (3.99) – (5.21)). Size of effect for
knowledge and behaviour changes cannot be quantified/compared across studies as there is
no single accepted unit of measurement for dental health knowledge or behaviour. Three
randomised trials in Scandinavia, reported in four papers12,14,15,19 (2+, 1-), all showed that
oral health promotion delivered by an oral health professional resulted in improved oral
hygiene. A quasi-experimental study in the USA16 (-), and another in Sweden4 (-) showed
improvements in plaque, gingivitis, and reported oral hygiene behaviour. However, the USA
study showed no effect on dmft (unchanged in intervention and control groups) in the short
term (2 months). One RCT reported in two papers17,18 (-) showed an effect on caries
incidence (New Caries: Test 0.71, Control 1.91; p<0.1). This intervention included fluoride
varnish application along with motivational interviewing. One RCT in the USA20 (+) showed
that educating parents could positively influence children’s behaviour in the dental surgery
(intervention behaviour 3.62, control behaviour 3.35, p<0.05). Overall there is strong
evidence suggesting that verbal oral health promotion by dental professionals has a positive
effect on patient knowledge, behaviour and gingival health, but the effect is insufficient to
impact on caries levels unless the use of fluoride is included.
The evidence reported is directly applicable to UK populations as disease levels, behaviour
and expected behaviours in the countries where the studies took place are largely similar to
the UK.
4
Jonsson et al. 2009 (-)
12,15
Hugoson et al. 2003, 2007 (+)
13
Blinkhorn et al. 2003 (+)
14
Hausen et al. 2007 (+)
16
Lepore et al. 2011 (-)
17,18
Weinstein et al. 2004, 2006 (-)
19
Jonsson et al. 2006 (-)
27
Oral Health: Approaches for general practice teams on promoting oral health
20
Wang et al. 2010 (+)
28
Oral Health: Approaches for general practice teams on promoting oral health
3.3.2 Is delivery of oral health promotion by leaflets/written material effective?
Studies
Humphris et al.
(2001 2001, 2004
UK
Humphris et al.
(2004)
Design
RCT
Quality
+
Validity
+
Population
Adult dental
patients
Intervention(s)
Leaflet
Comparison
Nothing
Parallel
RCT
+
++
Adult dental
patients
Leaflet
Nothing
Humphris et al.
(2003, 2004)
UK
Parallel
RCT
+
+
Adult medical
and dental
patients
Leaflet
Nothing
Boundouki et al.
(2004)
UK
Lees et al. (2000)
UK
RCT
+
+
Adult dental
patients
Leaflet
Nothing
RCT
+
-
Orthodontic
patients
Written
Video
and verbal
information
Three group
comparison
Audit of leaflets
Not applicable
Readability
Focus group
Not applicable
Verbal
Communication
preferred
Wanless (2001)
UK
Ashford
(1998)
Audit
-
+
Qualitative
+
N/A
Oral health
promoters
Students
Outcome
Knowledge
Intended
behaviour
Knowledge
Risk
perception
Knowledge
Attitudes
Intended
behaviour
Knowledge
distress
Plaque
Gingivitis
Behaviour
Positive result
Yes
Yes
Yes
Yes (marginal)
Yes
Yes
Yes
Yes
Yes (marginal)
Written
Video
Verbal
Yes
Plaque
Gingivitis
Behaviour
No
Yes
Yes
No
Yes
Yes
No
No
No
N/A
29
Oral Health: Approaches for general practice teams on promoting oral health
This section examines the evidence of effectiveness of delivering oral health promotion
messages by leaflet or in written form. We examined the evidence of effectiveness of leaflet
oral health promotion on knowledge, attitudes and aspects of behaviour but could find no
evidence concerning the effect of oral health promotion by leaflets on oral health outcomes.
Humphris et al.21,22 (+) investigated three hypotheses: first that a patient information leaflet
(PIL) would enhance patient perception of risk of oral cancer; second that the positive effect
of the leaflet on knowledge would be confirmed as in previous studies; and third that these
improvements would be associated with smoking behaviour. Adults (n=995) attending 20
general dental practices in Northern Ireland were invited to participate; 28 refused (response
rate=97%). Patients were randomised into two groups. The experimental group received a
PIL and then completed a self-report questionnaire, whereas the control group followed the
same procedure without the PIL. Measures included a 36-item oral cancer knowledge scale
and two items to assess risk perception. Usable data were available from 944 patients;
mean (SD) age=42 (15), 65% female. Risk perceptions of oral cancer were minimally
affected by the PIL (p=0.023). This effect was demonstrable in smokers. Smokers were
sixteen times (95% CI: 8–30) more likely to believe that they were at greater risk of oral
cancer than non-smokers. A clear benefit of the PIL on patients' oral cancer knowledge was
found, particularly for smokers and those with a history of smoking. These findings
demonstrate that public awareness of smokers can be raised with written information,
although health beliefs such as risk perceptions require more intensive intervention.
Humphris et al.22 (+) also showed that smokers knew less about oral cancer than nonsmokers (p< 0.05) when access to the leaflet had been denied. On receipt of the leaflet,
there was no difference in oral cancer knowledge between the smoking status categories of
respondents. Evidence of reassurance about screening from leaflet exposure was supported
by the second study. This research demonstrated an effect of a brief PIL to offset the
decrement in oral cancer knowledge observed in primary care patients who use tobacco in
comparison to their non-smoking counterparts. The leaflet reduced anxiety about oral health
screening in smokers. Smokers with access to the leaflet were more reassured and less
anxious about having an oral health screen (effect sizes: 0.30 and 0.32 respectively, p<0.05).
Humphris et al.23 (+) also attempted to determine if there was an immediate influence of a
validated patient information leaflet (PIL) on patient anxiety and intention to have a screen
for oral cancer in primary care attenders. The study involved patients (n=800) attending their
primary health care provider. Fourteen general practices (eight dental and six medical) in the
northwest of England took part. This was a randomised controlled trial with two arms: leaflets
were provided in the intervention group, and leaflets were absent in the control group. The
outcome measures were: intention to have an oral cancer screen, and anxiety towards a
screen, along with perceived risk of oral cancer. Knowledge of oral cancer, self-reported
dental service attendance history, and demographic variables were also collected. Patients
who had read the oral cancer PIL demonstrated an increase in their intention to have a
screen (Mann Whitney U test: z=−3.67, p<0.001) and reduced anxiety (Mann Whitney U test:
z=−2.07, p<0.05). Subjective risk was not elevated by the extra information. Intention to
have a screen was predicted by knowledge level and anxiety (odds ratios: 1.10 and 0.70
respectively, both p<0.001). They concluded that the influence of an information leaflet
appeared to have a positive effect on anxiety level and intentions to agree to receive an oral
cancer screen.
30
Oral Health: Approaches for general practice teams on promoting oral health
In a further report Humphris24 (+) described the immediate influence of a validated patient
information leaflet (PIL) on oral cancer and knowledge in primary care attenders. The results
showed that patients who had read the oral cancer PIL demonstrated a significant increase
in knowledge regardless of clinical setting (F [1,739] =246.24, p<0.0001). Patients showed
improvements in selecting the correct signs and risk factors associated with disease.
Immediate knowledge gain from a simple PIL about oral cancer was found and this was
independent of the primary care facility, where the PIL was distributed.
Humphris et al25 (+) reported a further a study which examined the influence of how a leaflet
on mouth cancer improves knowledge, related attitudes and intention to accept a mouth
screen. It was conducted as an RCT set in dental and medical waiting rooms in the North
West of England. Nine hundred and forty nine patients from 16 practices were invited to
participate, and standardised multi-item scales of six outcomes were measured including
knowledge, beliefs and intention to accept an oral cancer screen. A patient information
leaflet was given to an intervention group of patients. A single sheet questionnaire was
completed by both groups of patients immediately following leaflet administration in the
intervention arm of study; t tests were used to compare outcome variables between patients
with and without access to the leaflet. The participation rate was high (91%). A significant
increase in knowledge (p<0 .001) and improved screening intentions (p = 0.003) indicated
that patients benefited from having access to the leaflet. Anxiety was not raised with leaflet
exposure and some beliefs about the screening procedure appeared to be slightly improved
by reading the leaflet (p<0.05). The study supported previous findings of an immediate
positive effect of an information leaflet on patients’ knowledge of oral cancer and willingness
to accept an oral cancer screen.
Boundouki et al.26 (+) aimed to determine the influence of a patient information leaflet (PIL)
on mouth cancer to improve knowledge, reduce distress and increase intention to accept a
mouth screen over a two month period. The design was a randomised controlled trial. Two
dental practices in the northwest of England participated. Standardised multi-item scales of
the three outcome measures were employed. The PIL was given to a randomised
intervention group of patients in a waiting room. A single sheet questionnaire was completed
by both groups of patients at baseline in the waiting room (immediately following leaflet
administration in the intervention arm of study). The questionnaire was completed a second
time at eight weeks by all patients returning them via post. Mann–Whitney U-tests comparing
outcome variables between patients with and without access to the leaflet at baseline and 8
weeks were performed. Multiple logistic regression was used to predict re-reading of the
leaflet at home. Useable replies were received from 317 patients (60% response rate). All
measures showed some benefit of immediate exposure to the leaflet at follow up. Older
patients, less initial knowledge, and self-reported smoking positively predicted the re-reading
of the leaflet. The introduction of a mouth cancer PIL into dental practice may help to inform
patients about oral cancer, moderate distress and encourage acceptance of an oral health
screen.
In 2000, a study was reported27 (+) which compared the effectiveness of written, videotape,
and one-to-one instruction upon the knowledge, oral hygiene standard, and gingival health
of subjects undergoing orthodontic treatment with a lower fixed appliance. Participants who
had been recently fitted with fixed appliances were randomised into three groups: group 1
(n=21) received written oral hygiene instruction; group 2 (n=22) a watched a specially made
31
Oral Health: Approaches for general practice teams on promoting oral health
videotape; and group 3 (n=22) saw a hygienist for one-to-one instruction. Results were
assessed in terms of improvement in knowledge concerning oral hygiene procedures, and of
plaque and gingival index scores. Analysis of variance revealed no significant main effects or
interactions at p = 0.05, although the difference in the plaque index scores before and after
instruction was close to significance.
An audit28 (-) that assessed the quality of oral health promotion leaflets/literature by
examining their readability scores showed that leaflet design was often poorly thought
through and did not always offer accessible advice to patients. As it is clear that readability
is likely to impact on the effectiveness of written material, this study suggests that quality
assurance/control of oral health promotion literature might be helpful. This study indicated a
methodology by which the standard of readability and therefore, potentially the effectiveness
of written material might be improved.
Finally Ashford29 (+) reported a focus group study with 116 business students who did not
attend the dentist; most written communications were cited as impersonal; health posters
were perceived as negative as they were targeted at children only; and general media
articles on dentistry were considered not to be very evident or interesting.
Summary and Evidence Statement
The key finding from these studies is that conveying information via leaflet is an effective
way of changing knowledge and perhaps attitudes, but there is no evidence to suggest that
leaflets are better at conveying knowledge-improving information than other means,
including verbal delivery. There is weak evidence suggesting that written information may
not be as effective as verbal or video delivery for changing behaviour, and may not be some
patients’ preferred method of receiving information. Design and readability of leaflet
information is important and auditable. The data supporting these conclusions are based
largely on some high quality studies of the use of oral cancer leaflets in the UK. Assuming
cancer is not the key factor in the effectiveness, it is assumed leaflets containing other oral
health advice would be equally effective. If this is the case, the evidence supporting the
evidence statement should be considered strong.
Evidence Statement 3
Strong evidence from four RCT UK studies, reported in six papers21-26 (4+), suggests that
leaflets are an effective way of enhancing patients’ knowledge of oral cancer and reducing
associated fear and distress. One of these studies, reported in two papers21-22 (+) showed
that knowledge in the leaflet group increased more (30.87 (95% confidence intervals (30.51)
– (31.24)) than in the control group (26.11 (95% confidence intervals (25.7) – (26.48)) effect
size 1.29). An additional RCT27 (+) presented moderate evidence that written information
had less effect than verbal delivery or video delivery when educating orthodontic patients to
improve oral hygiene (PI % change, written = 1.48, video = 12.32, verbal = 18.7).
A UK audit study by Wanless28 (-) described how the readability of written oral health
promotion material might be improved and a qualitative study29 (+) indicated that young
males considered written information to be purely functional and impersonal.
32
Oral Health: Approaches for general practice teams on promoting oral health
There is therefore strong evidence that leaflets are effective for increasing patient
knowledge, but some weak evidence that they are less effective than other modes of
delivery. They are potentially less acceptable to patients than personal delivery of
information. No evidence was identified suggesting that oral health promotion in leaflets
affect health outcomes.
This evidence is applicable to patients attending dental practices in the UK as this setting
was relevant to the majority of these studies.
21,22
Humprhis et al. 2003, 2004 (+)
22
Humpris et al 2004 (+)
23,24,25
Humphris et al. 2004, 2001, 2001 (+)
26
Boundouki et al. 2004 (+)
27
Lees et al. 2000 (+)
28
Wanless. 2001 (-)
29
Ashford. 1998 (+)
33
Oral Health: Approaches for general practice teams on promoting oral health
3.3.3 Is delivering oral health promoting messages by means other than leaflet and verbal advice effective?
Study
Design
Quality
Validity
Population
Intervention
Comparison
Outcome
Vachirvaropisain et
al.(2005)
Thailand
Cluster RCT
+
+
Patients
attending
Health Centres
Individualised
health
education
Caries
Behaviour
O’Hara et al. (2008)
USA
Pilot study
-
+
Not applicable
Sbaraini et al.
(2008)
Pre/post
-
+
Patients with
intellectual
disability
Patients
attending clinic
Group
discussion
with/without
dental health
education
Personal digital
assistants
Assessment plus
demonstration by
dentist plus
5000ppm
toothpaste
Not applicable
Oral Health
(measure not
specified)
Caries
Dietary health
Positive
findings
No
Yes
N/A
Yes
Yes
34
Oral Health: Approaches for general practice teams on promoting oral health
In this section we examined evidence about oral health promotion interventions which
utilised methods other than the traditional giving of advice by a professional or the use of
written materials. The evidence we found was sparse and heterogeneous.
Vachirvaropisain et al.30 (+) conducted a cluster RCT in order to evaluate the process and
outcomes of a participatory dental health education (DHE) programme in group discussions
for preventing early childhood caries (ECC). In a one-year intervention programme set in 21
health centres, 520 mothers/caregivers of 6-19 month-old children who lived in a rural area
of Thailand, took part in “active involvement” group discussions of oral health in the
intervention group, and in the national teaching DHE programme in the control group.
Health centre staff evaluated the impact on children’s dental cavitated carious increment and
stated changes in oral health behaviour. After one year, the proportion of children using a
toothbrush and brushing with fluoride toothpaste was 97% in the intervention group,
significantly higher (p<0.01) than the control group (58%). Night time bottle-feeding, falling
asleep with a bottle and sweet snack diet behaviour appeared the same in both groups. The
proportion of children with cavitated caries increment was 74.2% and 68.1% in the
intervention and control groups respectively, i.e. the intervention group had slightly more
newly developed caries during the study than the control group. Health centre staff were
very supportive of the programme and suggested extending the participatory format to other
child health topics. The authors concluded that the participatory dental health education
model was shown to be a practical and effective method for increasing oral hygiene practice,
but was not sufficient to prevent the development of ECC. This study, although valuable, is
probably of limited applicability to the practice of oral health promotion in primary care
dentistry in the UK.
The only study identified which examined the use of technology was a pilot project in the
USA by O’Hara et al.31 (-), which evaluated the potential of Personal Digital Assistant (PDA)
technologies to improve the oral health of people with mild to moderate intellectual
disabilities, chronic health problems and a long-standing history of poor oral health self-care.
Oral health video and audio materials were prepared and transferred to PDAs. Patients were
trained in the use of the PDAs at a regular dental appointment and the utilization of the PDA
and any change in oral health status was tracked over the next six months. More than half of
the 36 patients reported problems in keeping the PDAs functioning properly (mainly
problems of keeping the batteries charged) for the duration of the project and 11 patients
dropped out of the study. Ten of the remaining patients (40%) achieved improvement in at
least three areas of oral health, which was measured on a four point scale along twelve
dimensions including gingival inflammation, calculus, mouth odour, and tongue coating. The
pilot project potentially brings a range of health promotion activities within the reach of
people with limited health literacy, which may produce better self-management of chronic
health conditions.
Sbaraini et al.32 (-) reported the effectiveness of a ten-step, non-invasive strategy to arrest
and remineralise early lesions. They gave patients a leaflet, verbal information, chairside
demonstrations of plaque, toothbrushing instruction, tooth paste and gel, and topical fluoride
applications. They considered the patient at risk, the status of each individual lesion, patient
management, clinical management, and monitoring. A total of 100 out of 146 smooth noncavitated carious surfaces at baseline had remineralised after six months, 99 per cent of
sound surfaces remained sound, and 23 new lesions were observed in six of the 20 patients
(α2 =292, 7 df, p<0.001). About half of proximal surfaces showing bitewing scores of grade 1
35
Oral Health: Approaches for general practice teams on promoting oral health
or 2 had regressed (α2 =86.66, 56 df, p<0.0001), and 95 per cent of proximal sound
surfaces at baseline, as diagnosed via bitewing radiographs, remained sound. The study
showed that a non-invasive approach to caries management, which combined intensive
coaching in oral hygiene maintenance, special home care and intensive monitoring in a clinic
for high-risk patients, was able to reduce gingival inflammation and maintain low plaque
levels, at least within the scope of this short-term study.
Summary and Evidence Statement
The evidence concerning ways of delivering oral health promotion via methods other than
verbal or written material is sparse. There is not yet any strong evidence to support the use
of technology as no robust scientific studies of the effectiveness of doing so were identified.
Group discussion may be helpful but this is probably not applicable in the context of general
dental practice.
Evidence Statement 4
4.1 Group discussions
There is strong evidence of the effectiveness of group discussions compared to standard
oral health promotion from a cluster RCT30 (+) carried out in Thailand, which involved
mothers of children aged 6-19 months. Both intervention and control groups received dental
health education and toothbrushes. The intervention group also participated in group
discussions conducted by trained moderators, which lasted about one hour. Group
discussions may be an effective adjunct to traditional dental health education in altering
behaviours, as 20% more mothers in the study reported that their child’s teeth were brushed.
The intervention did not have any effect on caries levels.
This evidence is probably not applicable to patients attending general dental practices in the
UK as group discussions with mothers of young children do not fit with the current model of
service delivery in the UK.
4.2 Technology
There is weak evidence concerning the use of technology for oral health promotion from a
small pilot study by O’Hara31 (-), in which 36 people with intellectual disabilities and poor
oral and general health were taught to use personalised digital assistants (PDAs), which
reminded and prompted them to undertake oral hygiene practices. The effectiveness of the
intervention was assessed by gathering anecdotal evidence from support care staff and by
the individuals by measuring oral health status using a 4 point scale. More than half of the
participants had difficulty with the technology, and 11 of 36 participants dropped out of the
study. Of the remaining 25, ten achieved improvement in oral health. There is therefore no
evidence that technology can be used to promote oral health in general practice.
The findings from this small study may not be applicable to the majority of people attending
general dental practices.
4.3 Clinical intervention with advice
There is weak evidence from a study in Australia32 (-), in which high risk young adult patients
(aged 18-35) underwent assessment of fortnightly coaching in oral hygiene and topical
fluoride. 20 patients, who were examined after six months attained and maintained lower
plaque levels, had decreased gingival inflammation, and had reduced rates of caries
36
Oral Health: Approaches for general practice teams on promoting oral health
progression. This study offers weak evidence that intensive oral hygiene instruction and
fluoride application can improve oral health.
However, the evidence is only partially applicable to the UK population attending general
dental practices due to differences between the UK and Australian system for dental care.
30
Vachirarojpisain et al. 2005 (+)
31
O’Hara et al. 2008 (-)
32
Sbaraini et al. 1994 (-)
37
Oral Health: Approaches for general practice teams on promoting oral health
3.4 What is the content of oral health messages and how does this influence effectiveness
Study
Design
Quality
Population
Intervention
Comparison
Outcome
-
External
Validity
++
Harris et al.
(2002)
UK
Survey
Dentists
Focus Group
questionnaire
Not
applicable
Survey
+
+
Dentists
Questionnaire
Not
applicable
Survey
-
-
Hygienists
Oral Hygiene
instruction
Not
applicable
Qualitative (+
survey)
+
N/A
Dentists
Focus group
Interview
Not
applicable
Qualitative
+
N/A
Dentists
Interview
Not
applicable
Qualitative
++
N/A
Oral Health
Professional
Focus Group
Interview
Not
applicable
Significant
numbers of
GDPs not
adhering to
guidelines re.
fluoride
toothpaste
Existence of
various barriers
to prevention
Average of 4
minutes spent
on oral hygiene
Variability in
advice given
especially
dietary
Advice not
targeted to
patients
Limited
knowledge re.
fluoride
toothpaste
Witton et al.
(2013)
UK
Ashkenazi et al.
(2014)
Israel
Holloway et al.
(1994)
UK
Threlfall et al.
(2007)
UK
Jensen et al.
(2014)
Sweden
Positive
findings
N/A
N/A
N/A
N/A
N/A
N/A
38
Oral Health: Approaches for general practice teams on promoting oral health
In this section we sought to synthesize any evidence concerning the content of oral health
messages in order that conclusions could be drawn about preferred and most effective
content.
In 2014, Jensen et al.39 (++) published a study in which the aim was to explore oral health
professionals’ (OHPs’) perspectives regarding their strategies, considerations and methods
when teaching their patients the most effective way of toothbrushing with fluoride (F)
toothpaste. A qualitative research method was used to collect data. Five groups of OHPs,
including dentists, dental hygienists and dental nurses were interviewed (n=23). The
interviews were analysed using manifest and latent qualitative content analysis. Data were
systematically condensed and coded to the relevant phrases that identified their content.
Three themes were identified: (a) strategies and intentions; (b) providing oral hygiene
information and instruction; and (c) barriers to optimal oral healthcare education. Health
promotion and seeing to the patients’ best interest were driving forces among the OHPs as
well as personal success in their preventive work. They focused on toothbrushing techniques
more than on how to use F toothpaste. Barriers to oral health information were to some
extent, the opinion of the OHPs, that some patients were impossible to motivate or that
patients already knew what to do. The OHPs described toothbrushing with F toothpaste as
very important, although the plaque removal perspective dominated. They did not focus on
how to use F toothpaste, because they believed that knowledge about and appropriate
behaviour concerning F toothpaste were already familiar to their patients.
Harris et al.37 (-) attempted to describe the knowledge and practice of general dental
practitioners (GDPs) (n=329) working in Liverpool (where there is no milk fluoridation
programme), St Helens and Knowsley, and the Wirral (where children have fluoridated milk
in schools and preschools) regarding the advice about fluoride toothpaste that was given to
child patients and their parents. Data were collected via a postal questionnaire sent to all
329 GDPs working within the three areas. GDPs working in more than one of the areas, and
those working in specialist orthodontic or oral surgery practices were excluded. Two hundred
and thirty-four (71%) questionnaires were completed and returned. Only 3% of dentists said
that no-one in their practice gave advice on the concentration of fluoride toothpaste to be
used. For caries free children under seven years of age, only 64% of GDPs gave advice
concerning the concentration of toothpaste which accorded with the available clinical
guidelines (British Society of Paediatric Dentistry). 28% of GDPs contradicted the guidelines
by advising children under 7 with high caries to use a low-fluoride toothpaste. Although 59%
of GDPs in the fluoridated milk areas asked the child whether they had fluoridated milk at
school, they did not appear to alter the advice given regarding the use of fluoridated
toothpaste. The study showed that a significant number of GDPs did not adhere to clinical
guidelines relating to the use of fluoride toothpaste when giving advice to their child patients.
A study by Holloway et al.33 (+) with 50 general dental practitioners working under a
capitation payment system for the treatment of children, showed that they all thought that
prevention on selected patients was of value to their practice. They said that prevention
enhances the reputation of the practice, adds to the job satisfaction of the dentist and is part
of modern dental philosophy. However, only when practised selectively would it be costbeneficial. The most popular preventive treatments were fissure sealants (particularly when
used on selected patients), oral hygiene demonstrations and, among a group of enthusiastic
dentists, dietary counselling. Dentists who employed hygienists had significantly higher
mean preventive awareness scores than those who did not.
39
Oral Health: Approaches for general practice teams on promoting oral health
A qualitative study by Threlfall et al.34,35, (+) assessed the content of preventive advice and
care offered by general dental practitioners to young children. This qualitative study using
semi-structured interviews in the North West of England involved 93 general dental
practitioners practicing within the general dental service. Each dentist was interviewed about
the care they provide to young children. The interviews were recorded, transcribed and
analysed using a constant comparative method. Preventive advice given to parents of young
children was usually about sugar consumption and tooth brushing behaviour, but the
emphasis and specific messages provided varied among the general dental practitioners.
Use of fluorides varied considerably, suggesting that some dentists either have reservations
or are unclear about the appropriate use of fluorides. The study indicates important
variations in the content of oral health promoting messages.
From the same interviews, Threllfall et al.35 (+) also reported in a second paper that children
with caries were more likely to be questioned about diet and oral hygiene if dentists believed
the parents to be motivated. If they were, the dentist was more inclined to spend time
providing advice. Most dentists seemed to believe that education was the key to preventing
caries and gave preventive advice in the form of a short educational talk. There was little use
of visual aids or material for parents to take home. Preventive advice was given in an ad hoc
way with no formal targeting and no props or additional materials. The authors concluded
that the use of visual aids, providing materials for parents to take home, and greater
emphasis on partnership would help improve the impact of advice.
Witton et al.36 (+) investigated the barriers and facilitators influencing the delivery of
prevention in accordance with a national guideline (Delivering Better Oral Health,
Department of Health England) in health service dental practice. Self-completion
questionnaires were sent via two mailings to all 508 dentists registered to work in health
service general dental practice in Devon, South West England. In total, 266 questionnaires
were returned (52% response rate). Examples of barriers and facilitators were evident at
various organisational levels of dentistry. These were principally the healthcare system,
practice (dental office) arrangements, and professional factors. Respondents gave positive
responses to questions concerning the flexibility (53%) and benefit of the guideline (63%)
and they tended to indicate that they didn’t perceive problems in changing their old routines
(58%). Opinion was divided among respondents on whether they felt patients followed their
advice (49%). There was overall agreement that delivering prevention in practice is
problematic if there are insufficient staff (68%), time (60%) or facilities (53%). Most
respondents felt adequately trained to deliver the evidence based prevention guidance
(59%). However, 32% of practitioners were likely to give advice which did not comply with
official guidance. This study identified barriers and facilitators to the delivery of prevention
guidance in this group of health service dentists and showed that no single factor was
viewed consistently as more important than any others.
In Israel, Ashkenazi et al.38 (-) investigated the extent to which dental hygienists target their
efforts toward patients' oral hygiene instruction. A population of 179 dental hygienists who
attended an annual meeting were given a structured anonymous questionnaire to assess
information concerning the content of their advice when instructing patients about oral
hygiene measures. The dental hygienists were females aged 21 to 68 years (mean age
39.05 ± 18.18); 49.7% worked in private practice, 21.7% in public practice, and 28.57% in
both. Overall, 70.9% reported that they provided oral hygiene instruction to all their patients;
28.5% to most of their patients; and 0.6% reported that they never provided oral hygiene
40
Oral Health: Approaches for general practice teams on promoting oral health
instruction. Among the participants, 54.5% reported giving instruction at every treatment, 41%
at every periodic treatment, and 4.5% only on first meeting. The reasons for not instructing
their patients included: the patient already knowing how to brush (61.5%); the patient
appearing uninterested (23.6%); and lack of time (21.7%). Most of the participants (77.7%)
reported giving the same hygiene instructions for patients at high and low risk for caries
and/or periodontal disease. Participants did not always use demonstration methods in order
to improve their patients' performance.
Summary and Evidence Statement
The available evidence about the content of oral health promotion messages in UK dental
practices is limited to surveys of content. Little work has been carried out to determine how
the content of oral health messages influences the extent to which they are positively
received and acted upon.
Evidence statement 5
Strong evidence about the content of oral health promotion was derived from six studies,
four of which were carried out in the UK (one study was reported in two papers)33-37 (3+, 1-),
one in Israel38 (-), and one in Sweden39 (++). These studies explored the content of oral
health promotion which is given in general practices. None of these studies examined the
effectiveness of the oral health promotion. One study37 (-) indicated that 28% of the advice
given about fluoride did not comply with British Society of Paediatric Dentistry guidelines and
another study36 (+) showed that 32% of practitioners were likely to give advice which did not
comply with official guidance. Two qualitative studies34,35,39 (1+, 1++) showed that the content
of the oral health promotion advice given, depended on the practitioner’s view of what the
receiver might be receptive to. Two studies33,38 (1+, 1-) indicated that oral hygiene instruction
was the preferred route for giving advice.
There is therefore moderate evidence that the content of oral health promotion messages
given in practice does not always accord with guidelines and official advice. There is
moderate evidence that content is tailored to the patients’ needs, expectations and apparent
motivations. There is no evidence as to how the content of oral health promotion impacts its
effectiveness, as none of the studies exploring content assessed the impact of content on
effectiveness.
This evidence is applicable to dental practice in the UK.
33
Holloway et al. 1994 (+)
34,35
Threlfall et al. 2007 (+)
36
Witton et al. 2013 (+)
37
Harris et al. 2002 (-)
38
Ashkenazi et al. 2014 (-)
39
Jensen et al. 2014 (++)
41
Oral Health: Approaches for general practice teams on promoting oral health
3.5 What influence do ‘receiver’ characteristics have on the effectiveness of oral health promotion?
Study
Design
Quality
Validity
Population
Intervention
Comparison
Comparison
Outcome
Levesque
et al. (2009)
Canada
Qualitative
+
N/A
Individuals
home on
welfare
Not applicable
Not applicable
Improved
content of
information
Loignon et
al. (2010)
Canada
Qualitative
+
N/A
Dentists with
exposure to
poverty
Development
of Oral Health
Promotion
materials via
collaborative
approach
Semistructured
interview
Not applicable
Not applicable
Themes of
importance
revealed
Rajabiun et
al. (2012)
USA
Poole et al.
(2010)
USA
Qualitative
+
N/A
HIV+ patients
Interview
Not applicable
Not applicable
Pre/post
test
-
+
Scleroderma
patients
DHE video +
exercises
Not applicable
Not applicable
Grant et al.
(2004)
Australia
Qualitative
+
N/A
Meurman et
al. (2001)
Finland
Controlled
Clinical Trial
-
+
Disabled
people’s
support
workers
Mutans
streptococci
positive
children
In depth
interviews
Not applicable
Not applicable
Oral Health
behaviour
influenced
Gingival
health
Pocketing
Oral hygiene
N/A
Oral health
promotion +
Xylitol
Oral health
promotion
Not applicable
Caries
Positive
findings
Recipients
identified with the
information given
Empathy and
communication
considered
important
Insight into
behaviour in
HIV+ patients
Yes
No
Yes
Care workers and
dentists perceive
oral health
differently
Socioeconomic
gradient in
effectiveness
42
Oral Health: Approaches for general practice teams on promoting oral health
A key ‘factor’ in any oral health promotion intervention is the receiver of it. This section
examines the studies in which the receiver group were defined by particular characteristics,
and the analysis seeks to determine the influence of receivers’ traits on the effectiveness of
oral health promotion interventions.
Levesque et al.43 (+) recognised that despite growing attention to the importance of cultural
competence and communication skills training in dentistry, very few initiatives had been
documented in relation to serving low-income populations. They produced an original videobased tool containing testimonies from six individuals who lived, or had previously lived on
welfare. The videotaped interview data represented perceptions and experiences regarding
their oral health, dental care service provision, and poverty in general. The content of the
resulting DVD, allowed a collaborative knowledge translation which improved interaction
between underprivileged people and dental care providers.
Levesque et al’s work was followed by a study by Loignon et al.44 (+) which aimed to identify
specific approaches and skills that dentists needed for more effective treatment of people
living in poverty, and addressing their needs. They conducted qualitative research based on
in-depth interviews with eight dentists practising in disadvantaged communities of Montreal,
Canada. Analyses consisted of interview debriefing, transcript coding, and data
interpretation. Results revealed that, over years of practice, these dentists had developed a
five-faceted socio-humanistic approach that involved: (1) understanding patients’ social
context; (2) taking time and showing empathy; (3) avoiding moralistic attitudes; (4)
overcoming social distances; and (5) favouring direct contact with patients. The authors
concluded that this approach should be evaluated terms of its impact on access to services
and patients’ experience of care.
Rajabiun et al.45 (+) reported on an intervention for people who were HIV positive, in which
participation resulted in better hygiene practices, improved self-esteem and appearance,
relief of pain, and better physical and emotional health. In-depth exploration of the causes for
these changes revealed a desire to continue with dental care due to the dental staff and
environmental setting, and a desire to maintain overall HIV health, including oral health.
These findings emphasise the importance of addressing both personal values and
contextual factors in providing oral health-care services to people living with HIV or AIDS.
A study by Poole et al.41 (-) investigated whether oral hygiene improved after people with
scleroderma received structured oral hygiene instructions and facial and hand exercises.
Seventeen people with scleroderma received a baseline dental evaluation including an
examination for decayed or missing teeth, calculus, sites that bleed upon probing, measures
of oral aperture, and the Patient Hygiene Performance Index. Upper extremity functioning
including strength, joint motion, and dexterity were also measured. Participants received a
structured home programme consisting of patient education on brushing and flossing
techniques, hand and facial exercises, adapted dental appliances, and a six-month supply of
dental products. At the end of the six-month intervention, there was a significant decrease
(improvement) in mean PHP scores and a significant decrease in the number of teeth that
bled on probing and with subgingival calculus. There were no differences in any of the upper
extremity measures or oral aperture. Correlations between the upper extremity and oral
measures showed associations between oral aperture and two of the dexterity measures
and number of teeth with caries. The authors concluded that oral exercises and education
regarding proper dental care may be useful in managing oral hygiene in persons with
scleroderma.
43
Oral Health: Approaches for general practice teams on promoting oral health
Grant et al.42 (+) undertook a qualitative study, based on a phenomenological approach,
which explored and documented four situations in which positive oral health outcomes
occurred for people with mental retardation and moderate to high support needs. Strategies
and environmental factors that contributed to these oral health outcomes were identified
through ten semi-structured interviews conducted with 'key-players' supporting the oral
health of the people with disabilities. Participants included dental professionals, direct
support workers, and other professionals who cared for their four people with disabilities.
Common strategies expressed in the interviews included "giving it a go"; maintaining
consistency; facilitating positive experiences; taking as much time as needed; respecting
and encouraging choice making: timeliness and frequency of dental appointments;
communication between support workers, dental professionals and the person with mental
retardation; problem solving; assisting the person with disability to learn skills; and
desensitisation. Contributing factors in the physical, social, and organisational environment
also were identified.
In 2001, researchers in Finland40 (-) studied an age cohort of 794 Finnish children (446 in the
intervention group and 348 in the control group) who were followed from 18 months to 5
years of age. The children were screened for mutans streptococci (MS) in the dental biofilm.
The main outcome measure was the proportion of children with dental caries (decayed,
missing, or filled primary teeth > 0) at the age of five years. The intervention, targeted to MSpositive subjects in the intervention group only, was based on repeated health education to
the caretakers and providing xylitol lozenges for the child. Dental hygienists carried out the
programme. The intervention was effective in white-collar families [numbers needed to treat
(NNT) = 3, 95% CI 2–11]. Factors significantly associated with caries at five years were MS
colonisation at 18 months, and the occupation of the caretaker. Gender was also significant
when incipient carious lesions were included in the index. Early risk-based oral health
promotion, targeted to the families of MS-positive children, can reduce the risk for caries in
white-collar families. For blue-collar families, different kinds of methods in caries prevention
and support are needed.
Summary and Evidence Statement
There is weak evidence that oral health promotion interventions designed for and with
specific receiver groups are effective. However, the evidence is mixed; the target groups are
highly heterogeneous and the outcome measures are variable. Firm conclusions regarding
the effect of receiver group on effectiveness are hard to draw, but weak evidence exists to
suggest that oral health promotion is most effective when the sender and receiver are of a
similar social group and understand the context of each other’s lives.
Evidence Statement 6
There is weak evidence from one controlled clinical trial40 (-), a before and after study41 (-)
and four qualitative studies42-45 (4+), suggesting that oral health promotion, especially
designed for very specific receiver groups, is effective in improving knowledge and attitudes.
Two Canadian studies43-44 (2+) using qualitative methodology, and one in Finland40 (-) using
quantitative methods, explored oral health promotion with deprived individuals. These
studies suggest that an understanding of the social context of oral health and the
development of relationships/collaborations are a vital part of developing oral health
promotion interventions for the underprivileged. Three studies, one carried out in Australia,
44
Oral Health: Approaches for general practice teams on promoting oral health
and two in America, examined oral health promotion for very specific special groups –
intellectually disabled42 (+), HIV positive individuals45 (+), and scleroderma patients41 (-). An
emergent theme from these studies is the need for collaboration and understanding between
professional and receiver groups. Thus, there is moderate evidence that the perceptions of
the receiver regarding their relationship with the sender, and the senders’ understanding of
the context of the receivers’ lives and behaviour, are relevant to their acceptance and
likelihood of acting upon oral health promotion messages.
These studies were all conducted outside of the UK so the results may only be partially
applicable to people attending dental practices in the UK, as the cultural and economic
provision for dental care for groups with special needs differs in North America, Australia,
and the UK.
40
Meurman et al. 2009 (-)
41
Poole et al. 2010 (-)
42
Grant et al. 2004 (+)
43
Levesque et al. 2009 (+)
44
Loignon et al. 2010 (+)
45
Rajabiun et al. 2012 (+)
45
Oral Health: Approaches for general practice teams on promoting oral health
3.6
What influence do ‘sender’ characteristics have on the effectiveness of oral health promotion messages?
Study
Design
Quality
Validity
Population
Intervention
Comparison
Outcome
Schouten et al.
(2003)
Netherlands
Brocklehurst et
al. (2013)
UK
Dyer et al.
(2006)
UK
Jensen et al.
(2014)
Sweden
Quasiexperimental
Survey
Qualitative
-
-
Patients attending
as emergencies
Observation
Not
applicable
+
N/A
Dentists involved in
OHP programme
Semi-structural
interviews
Not
applicable
Qualitative (+
survey)
+
N/A
Dentists (practice
principles)
Interviews plus
survey
Not
applicable
Qualitative
++
N/A
Oral Health
Professions
Focus Group
Interview
Not
applicable
Patient and
dentist
satisfaction
Three key
themes for
success
Views of
dentists who
should do OHP
Limited
knowledge
regarding
fluoride
toothpaste
Positive
findings
N/A
N/A
N/A
N/A
46
Oral Health: Approaches for general practice teams on promoting oral health
In this section we sought to determine which type of sender would be likely to be the best to
undertake oral health promotion to give it the best probability of being effective.
The aim of a study by Schouten et al.46 (-) was to examine the relations between patients'
and dentists' communicative behaviour and their satisfaction with the dental encounter. The
sample consisted of 90 patients receiving emergency care from 13 different dentists.
Consultations were videotaped in order to assess dentists' and patients' communicative
behaviour. Dentists' behaviour was coded by means of the Communication in Dental Setting
Scale (CDSS), scores for patients' behaviour included among other things, the number of
questions asked during the consultation. After treatment, patients filled out a questionnaire
that assessed their satisfaction with their own and their dentist's communicative behaviour.
Dentists also filled out a satisfaction questionnaire after each consultation. Results showed
that dentists' satisfaction could not be explained by patients' or dentists' communicative
behaviour. Patients' satisfaction was mainly influenced by the communicative behaviour of
the dentist. Not only is patient satisfaction positively related to the communicative behaviour
of dentists, but the principle of informed consent requires dentists also to inform their
patients adequately enough for them to reach a well-informed decision about the treatment.
A study by Dyer et al.48 (+) investigated the factors that might influence the provision of
general health promotion through seven different health interventions by dental teams in
general dental practice. A mixed-method approach was used comprising cross-sectional
qualitative research using semi-structured interviews of a purposive sample of ten practice
principals, and a cross sectional survey of a practice principal from every dental practice in
South Yorkshire, using a self-complete questionnaire. Two core categories emerged from
the qualitative data: seeing health or disease; and practitioners' views of the structure of
dental practice. The former refers to the participants' general outlook and cut across many
dimensions constituting the structure of dental practice. Health-orientated dentists were
more likely to be involved in prevention and were more open-minded to expanding the dental
team's role into general health promotion. However participants perceived that barriers
existed to involvement such as time and financial factors, current workload and lack of
personal skills. The response rate of useable questionnaires in the cross sectional survey
was 84%. Reported levels of involvement in general health promotion were low. Most
frequently reported barriers were 'insufficient funding' and 'poor use of time'. 'Poor use of
time' and 'lack of training/knowledge' were reported less frequently for professionals
complementary to dentistry (PCDs) than dentists (p<0.05). Most dentists agreed that PCDs
could be trained to deliver health interventions and would be happy for PCDs to do so in
their practice if reported barriers were removed. Although dental teams' involvement in
general health promotion is low, there is willingness to increase involvement, particularly
among health-orientated dentists. Some reported barriers to involvement might be removed
by impending changes to the General Dental Service in England. Other important factors
include a lack of education and workforce shortages of dentists and PCDs. Respondents
indicated a high regard for PCDs and there was broad agreement that they were suitable to
be involved in this work.
A further qualitative study47 (+) examined the perceptions of dentists who led a health
promotion programme called "Baby Teeth DO Matter". The clinical setting was in General
Dental Practice and participants were General Dental Practitioners in the Greater
Manchester-wide prevention programme "Baby teeth DO Matter". The purpose of the study
was to determine the perceptions of involved clinicians. Semi-structured interviews were
47
Oral Health: Approaches for general practice teams on promoting oral health
undertaken with a variety of participants in a health promotional programme facilitated by a
shadow Local Professional Network. These were then recorded and transcribed verbatim.
The transcripts were line numbered and subjected to thematic analysis to develop a coding
frame. Overarching themes were developed from the coded transcripts by organising them
into clusters based on the similarity of their meaning and checked against the coded extracts
and the raw data. Eight codes were generated: ‘Success of the project’; ‘Down-stream to upstream’; ‘Importance of clinically led and clinically owned’; ‘Keeping the approach simple’;
‘Importance of networking’; ‘Importance of Dental Public Health’; ‘Importance of task and
finish’; and ‘Threats to the future of the Local Professional Network’. These were organised
into three over-arching themes. ‘Clinically Led and Clinically Owned’ projects appear to
empower local practitioners and add value. They encourage community-facing practitioners,
build capacity and develop personal skills, all in accordance with the fundamental principles
of the Ottawa Charter. Distributed leadership was seen to be effective, and Dental Public
Health input "Task and Finishing" resources, and clarity of communication were all
considered to be of critical importance.
In 2014, Jensen et al.39 (++) published a study in which the aim was to explore oral health
professionals’ (OHPs’) perspectives regarding their strategies, considerations and methods
when teaching their patients the most effective way of toothbrushing with fluoride (F)
toothpaste. A qualitative research method was used to collect data. Five groups of OHPs,
including dentists, dental hygienists and dental nurses were interviewed (n=23). The
interviews were analysed using manifest and latent qualitative content analysis. Data were
systematically condensed and coded to the relevant phrases that identified their content.
Three themes were identified: (a) strategies and intentions; (b) providing oral hygiene
information and instruction; and (c) barriers to optimal oral healthcare education. Health
promotion and seeing to the patients’ best interest were driving forces among the OHPs as
well as personal success in their preventive work. They focused on toothbrushing techniques
more than on how to use F toothpaste. Barriers to oral health information were to some
extent, the opinion of the OHPs, that some patients were impossible to motivate or that
patients already knew what to do. The OHPs described toothbrushing with F toothpaste as
very important, although the plaque removal perspective dominated. They did not focus on
how to use F toothpaste, because they believed that knowledge about and appropriate
behaviour concerning F toothpaste were already familiar to their patients.
Summary and Evidence Statement
The available evidence did not allow comparison of the effectiveness of oral health
promotion given by different types of oral health professionals (e.g. dentist vs hygienist).
However, the studies included in this section suggest that traits of the sender influence the
effectiveness of oral health promotion. In particular the sender’s values and attitudes about
oral health and towards others seem to be important.
Evidence Statement 7
Evidence regarding the affect of sender characteristics was identified in four papers
including one quantitative46 (-) and three qualitative39,47,48 (2+, 1++) studies. These studies
explored aspects of the ‘sender’s’ influence on oral health promotion and how the sender
affects its potential effectiveness. A quantitative questionnaire study by Schouten46 (-), which
measured satisfaction with communication, gave weak evidence that a receiver’s responses
48
Oral Health: Approaches for general practice teams on promoting oral health
were influenced by the dentist’s ability to communicate. A qualitative study48 (+)
demonstrated that dentists who were networked to other oral health professionals, and
committed to prevention were more positive about oral health promotion. Another qualitative
study carried out in Sweden39 (++), showed that oral health professionals often assume that
patients have sufficient knowledge from other sources and do not need further advice. Two
studies39.48 (1++, 1+) suggested that holistically-thinking, health focussed (as opposed to
curative disease focused) professionals were more positive about oral health promotion.
There is therefore moderate evidence from qualitative studies to suggest that the beliefs,
attitudes and values of oral health professionals influence the likelihood of them participating
in and being positive about oral health promotion. No studies directly compared the
effectiveness of oral health promotion given by different members of the dental team,
therefore there is no evidence concerning the comparative effectiveness of different oral
health staff on the effectiveness of oral health promotion.
The evidence above is considered applicable to oral health promotion given in UK general
dental practices.
39
Jensen et al. 2014 (++)
46
Schouten et al. 2003 (-)
47
Brocklehurst et al. 2013 (+)
48
Dyer et al. 2006 (+)
49
Oral Health: Approaches for general practice teams on promoting oral health
3.7
What influence does framing of oral health promotion messages have on their
effectiveness?
No table is presented for this evidence statement as the evidence is from a single study.
This section reviews the evidence concerning how an oral health message is framed and
whether this has an effect on how a message is received, perceived and utilised. There was
very little evidence on this subject in the context of oral health promotion.
Arora49 (-) utilised a 2 × 2 factorial design to study the influence of framing and credibility on
messages designed to encourage a dental visit. A total of four different adverts were
designed to show various combinations of positive or negative framing of messages, with
low or high credibility. The adverts were designed to resemble a professional (albeit black
and white) appearance. Each advert had an introductory sentence followed by a list of
benefits. For example, the headline for the high credibility advert stated: ‘‘The National
Institute of Dental Research, part of the National Institutes of Health, has published its
findings on dental health. The report states that ‘‘Early detection of dental problems has
resulted in savings of about $100 billion (in 1990 dollars) from 1979 to 1989.’’ Early
Detection is the new watch word in dentistry.’’ The low credibility advert stated:
‘‘Conventional wisdom states that early detection of dental problems can result in significant
savings. Thus, early detection is the new watch word in dentistry.’’ The body was the same
for all adverts. Four benefits used in framing were: ‘‘Detect any cavity, determine if the gums
are healthy and free of gingivitis, detect any build-up of plaque on your teeth and keep your
original teeth for as long as you live.’’ However, for negative framing the attributes were
shown as benefits forgone by not following the advocated message. The first benefit was
stated as, ‘‘Will not be able to detect any cavity early’’ and so on. A hypothetical name was
used for the dental office, Dr. Thomas’s office. The framing of the message and the
credibility was accomplished in a similar manner as in previous studies (Maheswaran,
Durairaj, Meyers-Levy, and Joan 1990, Meyerowitz and Chaiken 1987). Two booklets were
prepared. One contained the instructions and the advertising stimuli (and filler adverts).
Subjects were instructed to look at the following adverts as they would at any advert in a
magazine. They were not informed as to which advert was the advertising stimulus and
which adverts were fillers. They were further instructed that after they had looked at the
adverts, they should put the booklet away and not refer to it further during the experiment.
The second booklet contained the questionnaire. The subjects for the experiment were
residents of a large midwestern city. The questionnaire included standard attitude and
intention questions. The attitude toward the dental office was assessed using an eight-point
semantic differential scale with end points as: good (bad) idea; wise (foolish) decision; and
excellent (poor) choice. The intention was measured by asking the subjects to indicate the
likelihood of choosing Dr. Thomas’s office for their dental exam. The end points were: very
likely (unlikely). In addition, respondents were asked to indicate the likelihood of
recommending dental exam to their friends. The end points of this eight-point scale were,
very likely (unlikely). They were asked aided and unaided questions to test the manipulation
of framing. Subjects were asked to write the benefits mentioned in the advert, to check
whether the statements were worded positively or negatively (containing the word not), and
the likelihood of receiving (or not receiving) the benefits mentioned in the advert. To test the
manipulation for credibility, they were asked to indicate the importance of early detection of
dental problems. The end points of the eight-point scale were: important and unimportant.
Two statements were used to test the manipulation of framing. The statements were
50
Oral Health: Approaches for general practice teams on promoting oral health
designed to measure the gains (losses) associated with the dental exam. Each statement
was measured on an eight point scale with end points as ‘nothing at all’ and ‘great deal’. For
the positive statement the mean scores were 5.81 (negative framing) and 6.23 (positive
framing). The difference was significant at p<0.001 (2 tail). The mean scores for the negative
statement were 6.70 (negative framing) and 5.59 (positive framing). The difference was
significant at p<0.001 (2 tail). The manipulation test for credibility was based on the
importance of early detection of dental problems. It is expected that the advert containing the
reference to ‘‘The National Institute of Dental Research’’ would be perceived as more
important. The test for difference in mean response was significant at p<0.01 (2 tail). The
mean values for low and high credibility were 6.08 and 6.67 respectively. These tests
support the manipulation of credibility and framing in the experiment. The attitude towards
getting the dental exam done was assessed using an eight-point semantic differential scale
with end points as: good (bad) idea; wise (foolish) decision; and excellent (poor) choice. A
reliability coefficient was calculated before arriving at the composite attitude score. The
standardised reliability coefficient alpha was 0.92 indicating that the three statements are
internally consistent. The influence of credibility and framing was tested using a two-way
ANOVA. The main effects for credibility and framing were significant (p< 0.001, and p=0.06
respectively). The interaction effect was not significant (p = 0.15). The intention to obtain the
dental exam was measured using an eight-point scale with end points as ‘not likely’ and
‘very likely’. Respondents were also asked to indicate the likelihood of recommending this
exam to their friends. The influence of credibility and framing on intention, as well as
recommending the service to their friends, was tested using a two-way ANOVA. The main
effects for personal intention to use the dental service were significant for credibility and
framing (p< 0.001, and p<0.01 respectively). The interaction effect is not significant (p=0.76).
Evidence Statement 8
There is weak evidence from one study49 (-) to suggest that the framing of oral health
promotion messages should be positive. This study examined the influence of message
framing and credibility on the receiver’s attitudes and intentions in the context of oral health.
This paper applied theories and previous study results to the oral health context. The study
suggested that the application of prospect theory (in which decision making is affected by
the perceived value of outcomes in the future) would imply that in relation to oral health
service usage, messages should be framed negatively (in terms of losses if the behaviour is
NOT taken up), but that health promoting messages should be framed positively (in terms of
benefit if the suggested behaviour IS taken up).
This study is probably only partially applicable to the UK as it was carried out in the US and
focused on attending a dental practice for an examination. Dental attendance is perceived
differently in the UK and USA and therefore the applicability may be limited.
49
Arora. 2000 (-)
51
Oral Health: Approaches for general practice teams on promoting oral health
3.8
What are the barriers and facilitators to effective oral health promotion?
Study
Jensen et al.
(2014)
Sweden
Design
Qualitative
Quality
++
Validity
N/A
Population
Oral Health
Profession
Barriers
 Lack of knowledge
 Patients social status / education
 Potential damage to relationship with
patient
Ashkenazi et al.
(2014)
Israel
Threlfall et al.
(2007)
UK
Survey
-
-
Hygienists
 Time
Qualitative
+
N/A
Dentists
Ashford (1998)
UK
Qualitative
+
N/A
Students
 Negative attitude and behaviour in
patient
 Lack of belief in patients’ willingness /
ability to change
 Lack of skill / props
 Poor quality of information delivery
Brocklehurst et
al. (2013)
UK
Qualitative
+
N/A
Dentist
 Lack of impact
 ‘Top – down’ approach
 Administrative support
Rajabiun et al.
(2012)
USA
Loignon et al.
(2010)
Canada
Grant et al.
(2004)
Australia
Witton et al.
(2013)
UK
Williams et al.
(2010)
Qualitative
+
N/A
HIV+ patients
 Attitude of staff
Qualitative
+
N/A
 Moralistic attitudes
 ‘Victim’ blaming
Qualitative
+
N/A
Survey
+
+
Dentists with
experience of
poverty
Supporters of
people with
disability
Dentists
Qualitative
and survey
+
N/A
Patients attending
health centre
 Negative experiences
 Hurried approach




Lack of resources + support
Lack of sense of comprehension
Older and Healthy patient
Knowledge and behaviour not linked
Facilitator
 Patient taking responsibility
 Professional feeling satisfaction when
improvements
Patients social status / education
 Background OHP / adverts
 Demonstration
 Belief in the efficacy of what is being delivered
 Clarity of underlying evidence


















Building personal relationship
Effective communication
Verbal rather than written material
Ability to use own initiative
Simplicity of approach
Being part of network
Dental Public Health Support
Awareness of link with HIV status
Sense of self-esteem feeling improved
Friendly supportive dental staff
Time
Empathy plus understanding
Accepting compromises
Consistency
Respecting choice
Communication with dentist
Good facilities, time resource
Sense that patient is receptive
 Single messages
 Message delivery by a person
52
Oral Health: Approaches for general practice teams on promoting oral health
Dyer et al. (2006)
UK
Qualitative
and Survey
+
N/A
Dentists
 Disease focused dentist
 Poor sense of competence
 Payment system




Health focused dentist
Perception of practice as health promoting
Team approach
Commitment
53
Oral Health: Approaches for general practice teams on promoting oral health
Many of the studies which contributed evidence regarding the other research questions in
the review, offered insights into the potential barriers and facilitators to effective oral health
promotion. This section draws together the recurrent themes within the available evidence,
concerning the factors which might enhance or diminish the probability of an oral health
promotion intervention being effective.
Jensen et al.39 (++) undertook a study to explore the oral health professionals' (OHPs')
perspectives regarding their strategies, considerations and methods when teaching their
patients the most effective way of toothbrushing with fluoride (F) toothpaste. For further
details see page 48.
Ashkenazi et al.38 (-) investigated the extent to which dental hygienists target their efforts
toward patients' oral hygiene instruction. For further details see page 40.
In a study to increase understanding about how and to whom general dental practitioners
provide preventive advice to reduce caries in young children, Threlfall et al34,35 (+) used a
qualitative study design using semi-structured interviews in the The North West of England.
For further details see page 40.
Ashford29 (+) reported a focus group study with 116 business students and lecturers who did
not attend the dentist. Focus groups (of one hour duration) comprising 6-7 members,
conducted over a period of 18 months, discussed five open-ended questions or statements.
116 non-attending males (aged between 25-34 years) consisting of professional lecturers
(17%), full-time students (50%), and part-time students (33%) with varying income and
education levels were included. A theoretical linear-sequential model related to patient
behaviour was considered in relation to the timing of communications but this was not tested.
Views of group members were collected concerning their attitudes, perceptions and
experience of communications from General Dental Practitioners. Informative oral
communications were considered as important during treatment. Most written
communications were cited as impersonal; health posters were perceived as negative, being
targeted at only children; and general media articles on dentistry were not very evident or
interesting. However, a practice brochure was viewed as a handy communication tool.
General Dental Practitioners should look carefully at all of their own methods of
communication with patients (from oral to written) and consider the value of their marketing
and all areas of communications, especially when considering non-attenders and males
(aged 25-34).
Brocklehurst et al.47 (+) used a qualitative approach to examine the perceptions of dentists
who led a health promotion programme entitled "Baby Teeth DO Matter". For further details
see page 47.
A qualitative study by Rajabiun et al.45 (+) explored the impact on oral health-care knowledge,
attitudes and practices among 39 people living with HIV/AIDS, participating in a national
initiative aimed at increasing access to oral health care. For further details see page 43.
Loignon et al44 (+) aimed to identify specific approaches and skills that dentists needed for
more effective treatment of people living in poverty and addressing their needs. For further
details see page 43.
Grant et al.42 (+) conducted a qualitative study, based on phenomenological approaches that
explored and documented four situations in which positive oral health outcomes occurred for
54
Oral Health: Approaches for general practice teams on promoting oral health
people with mental retardation and moderate to high support needs. For further details see
page 44.
Witton et al.36 (+) investigated the barriers and facilitators influencing the delivery of
prevention in accordance with a national guideline (Delivering Better Oral Health,
Department of Health England) in general dental practice. For further details see page 40.
Williams et al.50 (+) assessed patient awareness, in a dental access centre, of a poster and
leaflet campaign providing information about smoking and excess alcohol consumption as
risk factors in the development of oral cancer. Additionally, the study explored dental
patients' beliefs and perceptions about these risk factors. Posters and leaflets providing
information about risk factors for oral cancer were displayed in the patient waiting areas of a
dental access centre. Data were collected prospectively in relation to the smoking and
drinking habits of patients attending the centre. This information was used to categorise
patients into one of four groups ranging from low to high consumption. During triage, patients
were asked if they had read any of the information about oral cancer that was on display.
Patients in the high risk groups were asked to participate in a semi-structured interview that
would explore their knowledge about risk factors and their views on the delivery of
healthcare messages in relation to oral cancer. Data on risk status and exposure to the
poster and leaflet campaign were collected for 1,161 patients attending during the study
period. More than 50% of these patients were smokers, with 36% in the high or very high
tobacco and alcohol use groups. Approximately 40% of patients within each consumption
group had read some of the information available. Nine patients agreed to be interviewed
and overall knowledge about risk factors for oral cancer, even after reading the information
was poor. Dental access centres attract a significant number of patients with lifestyle habits
that make them vulnerable to oral cancer, and as such they are well placed to deliver oral
health messages to this high risk group.
Dyer et al.48 (+) investigated the factors that might influence the provision of general health
promotion through seven different health interventions by dental teams in general dental
practice. For further details see page 47.
Summary and Evidence Statement
There is moderate evidence that several barriers and facilitators affect the effectiveness of
oral health promotion. These relate to the senders beliefs about the content and the receiver;
the relationship between the sender and receiver, the senders satisfaction/enjoyment with
oral health promotion, and the resources available.
Evidence Statement 9
Strong evidence from 11 studies; seven qualitative, two surveys, and two mixed method
studies (1++, 9+, 1-) define barriers and facilitators to oral health promotion. Three
qualitative studies reported in four papers34,35,39,48 (1++, 2+) showed that dentists gave
messages which accorded with their own experiences and prejudices, and there was
moderate evidence that the sender’s belief in the credibility and effectiveness of oral health
messages affected the likelihood of them conveying them to the patient. The oral health
professional’s level of understanding of the ‘receiver’ was shown in four studies29,39,47,48 (1++,
3+) to act as a barrier or facilitator to effectiveness, and two studies39,48 (1++, 1+) showed
that if the sender felt commitment to, and enjoyment/satisfaction when promoting oral health,
55
Oral Health: Approaches for general practice teams on promoting oral health
this would act as a facilitator. There was also moderate evidence from three qualitative
studies42,44,45 (3+), that any pejorative or judgemental views held by the sender, concerning
the receiver of the message, would act as a barrier to oral health promotion. Three
studies38,48,50 (2+, 1-) indicated that lack of appropriate resources (knowledge, staff, time,
space) act as barriers to the delivery of effective oral health promotion.
This evidence is likely to be directly applicable to the UK situation.
29
Ashford. 1998 (+)
34,35
Threlfall et al. 2007 (+)
36
Witton et al. 2013 (+)
38
Ashkenazi et al. 2014 (-)
39
Jensen et al. 2014 (++)
42
Grant et al. 2004 (+)
44
Loignon et al. 2010 (+)
45
Rajabiun et al. 2012 (+)
47
Brocklehurst et al. 2013 (+)
48
Dyer et al. 2006 (+)
50
Williams et al. 2011 (+)
56
Oral Health: Approaches for general practice teams on promoting oral health
3.9
What factors affect patient satisfaction and motivation after a dental visit?
Although not strictly about ‘oral health promotion’, the scope of the review included a
requirement to appraise the evidence relating to patient satisfaction and motivation. We
suspect that our search strategy did not capture all the literature relating to this subject and
since completing the review, two studies that are likely to be relevant have come to light.
Because of the lack of research within dentistry on the relation between dentists’ and
patients’ communicative behaviour, and their satisfaction with the consultation, the purpose
of a study by Schouten et al.46 (-) was to gain more insight into this topic. It was expected
that patient satisfaction with consultations was determined strongly by the communication
behaviour of the dentist. The total score on the scale assessing patients’ satisfaction with a
dental visit was 78.6 (SD 9.0: range 19-95). Patients’ satisfaction with their own and the
dentists communicative behaviour was positively related to dentists’ communicative
behaviour (r=0.32: p=0.002): r=0.34: p=0.001 respectively). Scores on the communication
score sheet showed that dentists’ communicative behaviour towards dental patients is rather
neutral. In view of the legal requirements with regard to the information provision to patients
and the positive relationship between dentists’ communicative behaviour and patients’
satisfaction with emergency consultations, training dentists in communicative skills remains
of vital importance.
Mills et al.51 (++) also wished to develop an understanding of the key features of person
centred care (PCC) in relation to general dental practice from a patient’s perspective. The
study used qualitative methods to explore the views of 15 purposively sampled patients
living in Southwest England. In-depth semi-structured interviews were recorded, transcribed,
coded and analysed thematically. PCC was viewed as key in the delivery of high quality care
and therefore in patient satisfaction. Dimensions of PCC were identified and categorised as
functional or relational in nature. Two dimensions of functional care were identified;
healthcare system and physical environment. Five components of relational aspects of care
were identified: connection, attitude, communication, empowerment and feeling valued.
Mills proposed a model of patient centred care delivered from empirical evidence in the hope
that it would inform and influence development of improved patient satisfaction.
Ostberg52 (++) conducted a study investigating adolescents' perceptions and desires with
respect to oral health education. A series of focus group sessions were conducted with
adolescents, each group consisting of six individuals with a total of 34 participants. The main
theme of the discussions was the participants’ perceptions of oral health education including
in dental settings. The discussions were transcribed verbatim and analysed according to the
basic principles of Grounded Theory. One of the most important issues appeared to be that
the dental personnel should consider the individual as a subject and not an object. The
adolescents in the study were uncertain about their knowledge of oral health and expressed
a wish to be taught more when they went to the dentist. Two core categories labelled
“credibility” and “confidence”, which interacted with each other, emerged from the data. The
results indicated that the credibility of the staff delivering the message was essential, as was
their ability to inspire confidence.
Summary and Evidence Statement
The evidence suggests that the oral health professionals’ communication skills affect patient
satisfaction and motivation.
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Oral Health: Approaches for general practice teams on promoting oral health
Evidence statement 10
Three papers (one quantitative46 and two qualitative51,52) offered evidence regarding the
factors affecting patient satisfaction and motivation relating to a dental consultation. One of
these was carried out in Holland46 (-) and showed that patients who make decisions about
what is to happen to them are the most satisfied. The study also showed that patient
satisfaction was correlated to the way in which the dental professional communicated (r
=0.34 p< 0.001). In another qualitative study51 (++), it was shown that while the healthcare
system and the physical environment influenced patient satisfaction, relational aspects of
care, such as sense of connection, the dentist’s attitude, communication, and the patient’s
sense of feeling valued and empowered, were important factors in the patient’s satisfaction
with the care they receive and their relationship with the oral health promoter. In addition a
study in Sweden52 (++) showed that the credibility of the people in the dental surgery was
essential in oral health promotion, as was their ability to create confidence during a visit.
There is therefore strong evidence that positivity and communication affect patient
satisfaction and motivation.
It is likely that this evidence is applicable to UK populations as one of the studies took place
in the UK and the others in Holland and Sweden, which are culturally similar in terms of
relationships between professional and patients.
46
Schouten et al. 2003 (-)
51
Mills et al 2014 (++)
52
Ostberg 2005 (++)
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3.10 Linking oral health messages to wider health outcomes
One study was identified which examined the willingness of oral health practitioners and
their teams to become involved in delivering wider health messages48 (+) but no studies
testing the effectiveness of combining oral health promotion messages with such wider
issues were identified.
Evidence Statement 11
No studies published in English since 1994 were identified which specifically examined the
effectiveness of combining oral health messages with general health promotion. One study48
(+) investigated whether dental teams would be prepared to give patients general health
advice, but no studies were identified which tested the effectiveness of combining such
messages with oral health promotion. There is therefore no evidence on which to base
conclusions or recommendations about doing so.
48
Dyer et al. 2006 (+)
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Oral Health: Approaches for general practice teams on promoting oral health
3.11 Discussion
This review focused on oral health promotion activities that can be delivered in the context of
general dental practice, which aim to change individual’s knowledge attitudes or behaviours
in order to influence their oral health. It did not include legislative, regulatory, fiscal, or
organisational activities which influence health/oral health. This approach was taken in order
to ensure that the conclusions drawn could be applied by dental professionals in dental
practices in the UK. This is a much narrower context than that of the review published in
1998 by Kay and Locker. The current review worked from the principle that the evidence
base underpinning effective oral health promotion is well established and accepted
(Delivering Better Oral Health) and therefore the strategy was to determine ‘how’ oral health
promotion in the dental surgery should be carried out in order to optimise its effectiveness.
Confidence in the findings of this review stem from the methodology used. A broad search
strategy ensured that all relevant literature was potentially included. Assessment of the
quality, validity and applicability of the studies, and the data extraction process followed a
strict and audited protocol. However, the ability of any review to offer clear and unequivocal
conclusions is always limited by the quality and heterogeneity of the primary studies included
in the review.
The quality of the studies that were relevant to the subject under review was very variable,
and the outcome measures used to assess knowledge, behaviour and attitudes were ad hoc
measures and therefore only very rarely allowed direct comparisons between studies, and
entirely obviated the possibility of meta-analysing the data. Direct comparison between
studies and/or meta-analysis would have only been possible for studies that measured the
same clinical outcomes, and then only if the interventions had been the same. This required
level of similarity between studies was not reached.
Despite the fact that the context is slightly different, the findings of the review to some extent
echo the findings of earlier efforts to synthesise the evidence about oral health promotion
(Kay and Locker, 1998). This review, like the previous one, demonstrates that there is a still
lack of evidence to suggest that dietary change sufficient to affect oral health can be brought
about via oral health promotion in the dental surgery. Similarly, there is still no evidence that
caries that caries can be prevented by oral health promotion, although this apparent lack of
effect may be due, in part, to the short follow-up (<3 years) in the majority of studies. The
evidence that interventions involving the use of fluoride are effective remains strong, as in
the former review. In addition, as in the previous review, the studies demonstrating
reductions in plaque resultant upon oral health promotion were almost ubiquitously short
term and therefore evidence that changes in oral hygiene behaviour are sustained in the
long term is sparse. When oral hygiene is improved, gingival health is improved, and there is
robust evidence to support this.
Overall, a key theme that emerged, particularly through thematic analysis of the qualitative
research evidence, was the role of the sender of an oral health promoting message. The
literature strongly suggests that the success of oral health promotion interventions delivered
in dental practice by an oral health professional depends on that person’s character, values,
personality and people skills. And it is clear from this review that unless oral health
practitioners believe in the effectiveness and efficacy of the advice they are giving and are
convinced that it will truly make a difference to their patients’ well-being, they are unlikely to
practice oral health promotion activity successfully. Oral health practitioners therefore seem
to need to develop a sense of self-efficacy about their oral health promotion efforts. That is, if
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Oral Health: Approaches for general practice teams on promoting oral health
dental health teams were consistently achieving the desired objectives, they would be likely
to become more proficient and effective at delivering oral health promotion.
The lower rates of success of oral health promotion among some groups may be explained
by the fact that the greater the difference between the ‘sender’ of an oral health promotion
message and the ‘receiver’, the less likely the oral health promotion is to be effective.
Understanding and accepting the lives of patients and the context of oral health within those
lives, along with avoidance of negative judgements of those with poor oral health and
hygiene, helps to build the therapeutic alliance that is necessary for successful oral health
promotion in the dental surgery. This relationship between patient and oral health
professional, this therapeutic alliance, is a key factor in the success of oral health promotion
in the dental surgery. Thus, greater emphasis on teaching oral health professionals about
health psychology, and how people make choices, would make oral health promotion in the
surgery more effective.
The validity of the findings of this review are supported by the guidance published by NICE
in 2007 (PH6 Behaviour Change: the principles for effective interventions) and in 2014
(PH49 Behaviour Change: Individual Approaches) in that it is clear that the relationship and
understanding between the promotion ‘receiver’ and the promotion ‘sender’ is crucial to
success, as is the removal of barriers that prevent people from being committed to, and
believing in, the effectiveness of oral health promotion. Most importantly this review supports
the guidance given in PH49 that interventions should be based on proven behaviour change
techniques. This premise clearly applies as much to oral health as to any other behaviour
related disease as the current review shows that oral health promotion in the dental surgery
setting has a greater probability of achieving positive outcomes if it is based on an accepted
model of behaviour change and accepted psychological techniques.
The dental surgery setting offers an opportunity to offer smoking cessation advice, and the
relationship of smoking to oral, as well as general disease suggests that smoking cessation
advice can and should be given by dentists. There is evidence that giving such advice does
increase the probability of smoking abstinence. However, just as for other oral health
promotion messages, lack of resources (time, reimbursement), lack of training in how to
appropriately offer advice, and concerns about how such advice will be viewed by patients,
act as barriers to oral health practitioners involving themselves in this area of health
promotion.
3.12 Conclusions

There is strong evidence that oral hygiene and gingival health can be
improved by using psychological behaviour change models as the basis of
the intervention.

There is strong evidence that patients’ knowledge levels can be improved by
receiving oral health messages from an oral health practitioner.

There is strong evidence that leaflets and written material are effective in
promoting patients’ knowledge, but no evidence that leaflets are effective for
changing people’s behaviour.

There is strong evidence that a number of barriers and facilitators to the
successful delivery of oral health promotion in the dental surgery exist.
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Oral Health: Approaches for general practice teams on promoting oral health

There is moderate evidence that patient motivation and satisfaction are
dependent on the oral health professionals’ communication skills and ability to
build therapeutic alliances with their patients.

There is moderate evidence that the nature (but not the professional role) of
the ‘sender’ of oral health promotion messages and their attitudes and beliefs
about oral health promotion can act as either a barrier or facilitator to
effectiveness.

There is weak evidence that improvements in knowledge lead to improved
oral health behaviour, at least in the short term.

There is no evidence available regarding the effectiveness of linking oral
health promotion messages to wider health outcomes.
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4. Evidence Tables
Evidence tables have been presented in alphabetical order.
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Arora
Source
Population(s):
Country of study
(include if developed
or non-developed)
USA
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): NR
Behavioural results:
Limitations identified
by author: NR
Setting: NR
Report how confounding
factors were minimised: N/A
not a controlled study.
Outcome name:
Attitude
Outcome definition:
The attitude towards
the dental exam
Outcome measure: 8
point semantic
differential scale
Outcome measure
validated: NR
Year: 2000
Citation: Arora, R.
(2000) Message
framing and
credibility:
Application in dental
services, Health and
Marketing Quarterly,
18(2), 29-44.
Country of study:
USA
Aim of Study: To
test the influence of
message framing
and credibility on the
attitude toward a
dental exam and
consumers’ intention
to use the dental
office.
Study Design: A 2
x 2 factorial design.
A total of 4 different
ads were designed
Location (urban or
rural): Urban
Sample
characteristics:
Age: 25-55
Sex: 40% male and
60% female
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education: 33% high
school graduates,
67% college
graduates.
Socioeconomic
Programme/Intervention
description:
What was delivered: A total of
four different adverts were
designed to show various
combinations of positive or
negative framing of message,
with low or high credibility. The
adverts were designed to
resemble professional
appearance. Each advert had
an introductory sentence
(showing credibility e.g. national
institute of dental research or no
professional mentioned). For
the framing element four
benefits were used. In the
positive framing condition
‘detect any cavity, determine if
Unit of measurement:
good (bad) idea, wise
(foolish) decision,
excellent (poor) choice.
Time points
measured: At the end
Outcome name:
Intention to attend the
dental office
themselves
Outcome definition:
Intention to attend the
dental office
Outcome measure: 8
point Likert scale
Outcome measure
validated: NR
Intervention
group(s): Attitude
Baseline: NR
Follow up: NR
End point:
Low credibility,
negative framing:
Mean=5,
Low credibility,
positive framing:
Mean=4.9
High Credibility,
negative framing:
mean=6.3
High Credibility,
positive framing:
Mean=5.6
The standardised
reliability coefficient
alpha was 0.92
indicating that the
three statements are
internally consistent.
The influence of
Limitations identified
by review team:
No information on
source population.
Methods of
recruitment were not
mentioned so there is
no indication of
whether eligible
sample was
represented or not.
Inter-rater reliability
was not reported on
for intention only
attitudes.
Experimenters were
not blind.
None of the oral health
related outcomes were
assessed although
knowledge, attitude
and behavioural
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
to show various
combinations of
positive or negative
framing of message,
with low or high
credibility. Each ad
had an introductory
sentence followed
by a list of benefits.
position: NR
Social capital: NR
your gums are healthy and free
of gingivitis, detect any build-up
of plaque on your teeth and
keep your original teeth for as
long as you live’) and for the
negative framing condition ‘will
not be able to detect any cavity
early’. (p35-36)
Quality Score (++,
+, or -): External
Validity(++, +, or -):
+
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): NR
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR
Inclusion Criteria:
NR
Exclusion Criteria:
NR
% of selected
individuals agreed
to participate: NR
Potential sources of
bias:
2 booklets were given to the
participants, one containing the
advert (amongst other adverts)
and one contained the
questionnaire. They were
instructed to look at it like they
would a magazine. They were
not informed of which advert
was of interest. They were
further instructed that once they
had finished looking at the
leaflet they should put it away
and not refer to it again for the
second part of the experiment.
(p.36)
The questionnaire included
standard attitude and intention
questions. The attitude towards
the dental office was assessed
using an 8 point semantic
differentiation scale. The
intention was measure by
asking the participants to
indicate the likelihood of
recommending a dental exam to
a friend. This was an 8 point
Outcome definitions
and method of
analysis
Unit of measurement:
Not likely to very likely.
Time points
measured: At the end
Outcome name:
Intention to recommend
having a dental
examination
Outcome definition:
Intention to recommend
to friends
Outcome measure: 8
point Likert scale
Outcome measure
validated: NR
Unit of measurement:
Not likely to very likely.
Time points
measured: At the end
Method of analysis
(indicate if ITT or
completer analysis was
used and if
adjustments were
made for any baseline
differences in important
confounders): An
ANOVA was used to
test for the main effects
between the conditions
Results
Notes by review
team
credibility and framing
on attitude are
significant (p<.001 and
p=.06 respectively).
The interaction effect
is not significant
(p=.15).
outcomes were.
Intervention
group(s): Intention
Baseline: NR
Follow up: NR
End point:
Low credibility,
negative framing:
Mean=3.8
Low credibility,
positive framing:
Mean=2.9
High Credibility,
negative framing:
mean=5
High Credibility,
positive framing:
Mean=4.3
No information was
given on effect sizes
and no confidence
intervals were given.
Evidence gaps:
The results for
interaction are mixed.
It is not significant for
personal attitude and
personal intention, but
it is significant when it
comes to
recommending dental
examinations to
friends. This needs
further investigation.
Source of funding:
NR
The main effects for
personal intention to
use the dental service
were significant for
credibility and framing
(p<.001 and p<.01
respectively). The
interaction is not
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Likert scale. (p.36)
Theoretical basis: Prospect
Theory, Kaleman and Tversky
(1979). (p.30 para.5)
By whom: NR
To whom: Participants
How delivered: The adverts
were given in the booklets,
there were 4 different booklets
containing the different framing
and credibility messages and
then a second booklet
containing the questionnaire.
When/where: NR
How often: Once
How long for: NR
Control/Comparator
description: N/A
What was delivered:
By whom:
To whom:
How delivered:
When/where:
How often:
How long for:
Sample size at baseline: N/A
Total sample N = 210
Intervention group N = 210
Control Group N = N/A
Baseline comparisons (report
any baseline differences
Outcome definitions
and method of
analysis
and attitude and
intention.
Results
Notes by review
team
significant (p=.76).
The main effects for
intention to
recommend the dental
service to friends were
also significant for
credibility and framing
(p<.001 and p<.02
respectively). The
interaction is also
significant (p=.01).
Attrition details:
Indicate the number
lost to follow up and
whether the proportion
lost to follow-up
differed by group (i.e.
intervention vs control)
NR
Conclusion: The
findings indicate a
strong effect of
credibility on attitude
as well as intention.
The influence of
framing is also
significant on attitude
and intention. The
results for interaction
are mixed. It is not
significant for personal
attitude and personal
intention, but it is
significant when it
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Study details
Population and
setting
Method of allocation to
intervention/control
between groups in important
confounders): NR
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of
analysis
Results
Notes by review
team
comes to
recommending dental
examinations to
friends.
The author then goes
on to discuss the
findings on this
research in relation to
other health areas
such as BSE, surgery
and credit card usage,
for marketers
considering using
framing and credibility.
That is, messages
should be framed
negatively indicating
the loss by not using
the services or loss by
switching to other
untried services, whilst
‘prevention behaviour’
should use positively
framed behaviour.
Considering the joint
effects of framing and
credibility trying to
gain new customers
should consider the
use a positively
framed strategy with a
credible source and
those who offer free
services should
consider using
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
negatively framed
messages using
credible sources.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
Notes by Review Team
Author: Ashford, R,
A.
Study design:
Focus groups (of 1 hour
duration) comprising 6-7
members, conducted over a
period of 18 months, discussing
5 open-ended questions.
Population the sample
was recruited from: The
respondents were manly
taken from part-time and
full-time business and
management students who
were studying on an
undergraduate or
postgraduate programme
(p.236, pa.9).
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Sample frame:
concentrated on
respondents in the North of
England, mainly
undertaking some form of
education. (p.238, pa.3)
Year: 1998
Citation: Ashford,
R.A., An
investigation of male
attitudes toward
marketing
communications
from dental service
providers. British
Dental Journal,
1998. 184(5): p. 2358.
Country of study:
UK
Quality Score (++,
+, or -): +
Research aims, objectives,
and questions:
Objective: To identify the
process by which males aged
25-34 who do not display regular
attendance behaviour are
exposed to, attend, comprehend
and are persuaded by
communications by general
dental practitioners.
Theoretical approach
[grounded theory, IPA etc]:
NR. Previous research is based
on the DAGMAR model - linear
sequential communications
model (p.236, para.2) – but this
was not tested in this research.
State how data were collected:
What method(s): Focus groups
taken from a stratified random
sample of males (segmented by
age 25-34). The groups
comprised respondents who
were non-attenders overall (this
was determined before the focus
groups were undertaken). A cutoff point of 2 years was used as
How sample was
recruited: Prior to setting
up the focus groups, the
respondents were engaged
in a general lecture style
discussion on research
methods and their
limitations. The discussion
then led to the general
dental experience, where
the researcher was able to
identify the attenders and
non-attenders. (p.236,
pa.9)
How many participants
recruited: n=116. Each
focus group comprised 6-7
males. (p.236, pa.9)
Sample characteristics:
Age: 25-34 years of age
(p.236, pa.8)
Sex: males
Sexual orientation: NR
Each focus group was tape recorded
and external administrative staff used
for the transcription of the tapes. The
analysis was undertaken by the
author using the semantical analysis
technique. (p.237, para.2)
Key themes and findings relevant
to this review [with illustrative
quotes if available] (p.237)
Importance of effective
communication:
- Generally it was considered by all
groups that not enough information
(oral or written) was given by the
dentist, either on preventive
treatment or what they are actually
doing as they complete the treatment
or check.
- Being informed about treatment and
cost was particularly important to
respondents. Only about 30%
remembered discussing treatment
and cost prior to their treatment.
“I need to know what he (the dentist)
is doing to me and what it’s going to
cost”
Attitudes to written communication:
- Many identified that
Limitations identified by
review team:
Role of researcher is not
clearly described.
Only one method of data
collection used.
Analysis undertaken by
author only.
Evidence gaps and/or
recommendations for
future research:
Further research
recommendations:
Service quality, dentists’
attitudes to the adoption of
a more customer friendly
provision of services to
NHS patients/customers in
light of the current political
instability affecting fund
allocation. (p.238, pa.6)
Source of funding: NR
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Study Details
Research Parameters
the criteria for a non-attender.
The focus groups took place
during lectures and were
compulsory for the age group
concerned – therefore resulting
in no refusals. 5 basic openended questions or statements
were posed at appropriate
intervals and participants were
invited to share their views and
relate to their experiences.
The statements/questions were
as follows (although there was
slight variations/adaptions of
wording between groups):
- comment on the importance of
effective oral communication
from the dentist
- What are your attitudes to
practice brochures?
- What do you think about dental
care promotional posters in the
dentist’s waiting room?
- Have you ever read articles in
magazines on dentistry, targeted
specifically at males? (p.237)
By whom:
What setting: The largest nonfederal university in the UK
(based in the North).
When: Over a course of 18
months from 1995-1996
Population and Sample
Selection
Disability: NR
Ethnicity:
Religion:
Place of residence: From
university in the North of
the UK (p.236, para.9)
Occupation: Range:
lecturers, part time
students who are
managers in a variety of
industries, full-time
students (Table 1, p.237)
Education: University
level: range from
undergraduate to PhD level
(Table 1, p.237)
Socioeconomic position:
Range: From low income;
to middle income; to upper
to middle income (Table 1,
p.237)
Social capital: NR
Inclusion criteria: Age 2534. Male. A cut-off point of
2 years was used as the
criteria for a non-attender
(p.236, para.8)
Exclusion criteria:
Outcomes and Methods of
Analysis
communications related to lack of
attendance and the perceived threat
of having to go private.
“I’ve had many letters saying that if I
don’t go and see them soon, he’ll
knock me off the list – is this going to
encourage me?”
Notes by Review Team
“The letters are bland, perhaps they
need to be more friendly and
interesting”
Attitudes to practice brochures:
Only 2 respondents out of the 18
groups had seen a practice brochure.
Attitudes to dental care promotional
posters in the dentist’s waiting room:
- General perception that posters
were aimed at children.
- Not generally perceived as credible.
Articles in magazines on dentistry:
- General response was negative as
most had not read an article
specifically aimed at males.
“Even if it was there I’d skip it – not
interested”
Conclusions: (p.238)
It was felt that dentists should take
time to talk to the patients specifically
to explain what treatment is being
administered, preventive dental care
and the costs.
Use of written information was
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
perceived as functional and
impersonal.
Notes by Review Team
Most of the sample group had not
seen a dental brochure and dental
posters were perceived as not
always credible. There was little
experience in reading articles.
In light of the findings there are some
key points which are important for
marketing communications for dental
services:
The traditional response hierarchy
model needs to be adapted – the
dentist must consider the time period
during and after the patient has
purchased the service and target the
communications specifically for these
periods.
The dentist must consider the
opportunities with the reluctant
patient when they arrive for an
appointment. These opportunities
are: to build a personal relationship
by providing educational informative
and caring information, use written
communications more fully in
customer-orientated manner, use the
surgery and staff within the surgery
more fully.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
Author: Malka
Ashkenazi, Ortal
Kessler-Baruch &
Liran Levin
Source Population(s):
Israeli Dental
Hygienists
Method of allocation (Describe
how selected individuals/clusters
were allocated to intervention or
control groups – state if not
reported): N/A – this was not a
controlled study.
There are no
outcomes as this
is not an
intervention
Oral hygiene
instruction:
Limitations identified
by author:
One limitation of this
present study is its
self-reported nature.
This might be subject
to bias and to
inaccuracies of selfevaluation. Another
limitation is the
selection bias of those
who attended the
annual meeting and
completed the
questionnaire. (p.269
para 5)
Year: 2014
Citation:
Ashkenazi, M., O.
Kessler-Baruch,
and L. Levin, Oral
hygiene
instructions
provided by dental
hygienists: results
from a self-report
cohort study and a
suggested protocol
for oral hygiene
education.
Quintessence
International, 2014.
45(3): p. 265-9.
Country of study:
Israel (p.266
para.4)
Aim of Study: This
study was
undertaken to
evaluate
respectively the
preventive
Setting: National
meeting of the Israel
Society of Dental
Hygienists (p.266
para.4)
Location (urban or
rural): NR
Sample
characteristics:
Age: Mean=39.05
(SD=18.18) (p.266
para.11)
Sex: All females (p.266
para.11)
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Israel
Occupation: Dental
hygienists: private
practice only= 49.7%;
public practice only=
21.7%; both public &
private= 28.57% (p.267
para.2)
Report how confounding factors
were minimised: [quality
assessment]
Method description:
What was delivered: A structured
questionnaire was designed by the
authors to assess demographic
characteristics of the dental
hygienists as well as the extent to
which they targeted their efforts
toward their patients’ guidance and
education. Questionnaires were
used to collect information on the
preventive care activities of dental
hygienists, and recorded information
regarding age, seniority and their
habits in instructing their patients
about oral hygiene measures. (p.
266 paras 5-6)
Sample size at baseline:
Total sample N = 179 returned
questionnaires
Baseline comparisons (report any
Method of
analysis (indicate if
ITT or completer
analysis was used
and if adjustments
were made for any
baseline
differences in
important
confounders):
Differences in
prevalence of
different instruction
methods provided
by dental hygienists
were determined
using chi-squared.
Analyses were
performed using
SPSS. (p.266
para.7)
Correlation
between means of
instruction and age
or type of dental
clinic was
determined using
the Pearson
127 (70.9%) reported
that they provide oral
hygiene instruction to
all their patients; 51
(28.5%) to most of
their patients and 1
(0.6%) reported that
she never does.
(p.267 para.3)
Regarding frequency
of oral hygiene
instruction:
Every meeting: 97
(54.5%)
Every periodic
treatment: 73 (41%)
Only in the first
meeting: 8 (4.5%)
Never: 1 (0.6%)
(p.267 para.3)
Reasons for not
instructing patients
included:
 Lack of time
(21.7%)
 No need since
the patient knows
Limitations identified
by review team:
The study took place
in Israel (a developed
country) but the
characteristics of
Israeli dental provision
were not provided.
This is unlikely to be
the case due to the
nature of the sample.
This was a
convenience sample
drawn entirely from
attendees at the
71
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
instruction provided
by dental
hygienists and to
investigate the
extent to which
they targeted their
efforts toward
patients’ guidance
and education.
(p.266 para.3)
Education: NR
Socioeconomic
position: NR
Social capital: NR
baseline differences between
groups in important confounders):
N/A. – no control group
Study Design:
Cross-sectional
survey of dental
hygienists carried
out during the 2012
national meeting of
the Israel Society
of Dental
Hygienists. (p.266
para.4)
Quality Score (++,
+, or -): External
Validity(++, +, or ): -
Eligible population
(describe how
individuals, groups, or
clusters were recruited,
e.g. media
advertisement, class
list, area):
State if eligible
population is
considered by the
study authors as
representative of the
source population: All
dental hygienists who
arrived at the
convention were asked
to complete an
anonymous structured
questionnaire.
Inclusion Criteria: The
study included all
dental hygienists who
attended the annual
meeting and completed
the questionnaire.
Exclusion Criteria:
NR
Study sufficiently powered (power
calculations and provide details):
NR
Outcome
definitions and
method of
analysis
correlation test.
(p.266 para.8)
Results
Notes by review
team
how to brush
(61.5%)
 Patient is
uninterested in
receiving
instructions
(23.6%)
 Instruction does
not improve the
oral hygiene of
patients (0.6%)
(p.267 para.3)
national meeting of the
Israeli Society of
Dental Hygienists.
Thus the study
excluded Dental
Hygienists who were
not members and any
members who couldn't
make it/ decided not to
go to the meeting.
There is no indication
of whether or not
these groups would
have differed in any
way from the
attendees but there is
a strong possibility that
they did.
% which encouraged
their patients to use
specific hygiene aids
 Toothbrush 97.2%
 Flossing – 57%
 Wooden tooth
pick – 34.1%
 85.5% - plastic or
rubber toothpick
 67.6% interproximal
brush
 45.8% - mouth
rinsing
 32.4% - water
pick
(p.267 para.4)
An average of 4.32
(SD: 2.09 minutes)
At 60% the response
rate was good but the
reasons for refusal are
not provided even
though this may have
caused selection bias.
There is information
on whether or not
refusers significantly
differed in
characteristics like
location of practice,
gender or age. The
fact that all the
participants were
female may reflect the
72
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
% of selected
individuals agreed to
participate: 60% of
300 dental hygienists
asked (n=179) (p.266
para.9)
Potential sources of
bias:
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
instructing and
educating their
patients. (p. 267
para.5)
demographics of this
occupation in Israel
but in the absence of
any data on this, it
raises the possibility
that it could be a result
of selection bias.
About one fifth of the
participants (22.2%)
reported instructing
patients at high risk of
carries and/or
periodontal disease
while 77.7% reported
giving the same
instructions. (p.267
para.7)
No correlation was
found between the
reported duration for
providing oral hygiene
instruction and type of
instruction. Similarly
no correlation was
found between
means of instruction
and age, seniority,
place of graduation,
and type of dental
clinic. (p.268 para.1)
Further details about
the distribution of
dental hygienists’
reports regarding the
means used for oral
As noted by the author
selection bias was
possible due to the
use of a convenience
sample.
The paper implies (but
doesn't make explicit)
that the questionnaires
were given out at the
conference and
‘returned’ to the
researchers (as
opposed to the
researchers running
through the
questionnaire with
each respondent in
turn) (p.266 para.9).
Assuming this is the
case a contamination
effect might occur if
some of the
respondents discuss
the questionnaire with
each other before
returning them. This is
73
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
hygiene instruction
are included in Table
1 of the paper.
not mentioned in the
paper.
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs.
control) N/A. – this is
not a longitudinal
study.
Conclusion:
According to the
present report it
seems that dental
hygienists in the
tested group do not
make enough effort to
educate and instruct
their patients
regarding oral
hygiene preventive
measures. On
average dental
hygienists in studied
cohort spent
approximately 4
minutes discussing
oral hygiene. Dental
hygienists were also
Because the study
relies on self-reported
data validity is likely to
be poor as dental
hygienists may not
report what they
actually do but what
they feel they should
do.
No test of reliability
was reported. The
measures were selfreported.
Outcomes were not
set out before the
results so it is
impossible to say
whether any outcomes
were not reported.
While Chi Squared
and Pearson's
Correlation Coefficient
were used the results
are not presented in
the report.
Evidence gaps: NR
74
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
not employing
effective strategies in
the selection of
patients most in need
of intensive
instructional efforts,
and did not use
sufficient
demonstration
methods in order to
improve their patients’
performance. (p.269
para.30)
Source of funding:
NR
75
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author: Blinkhorn,
A. S. et al
Source
Population(s):
Children aged 1-6 in
general dental
practices in the West
Pennine District of
North-West England.
The district is made
up mainly of the 2
boroughs of
Tameside and
Oldham, both
relatively
economically
disadvantaged with a
considerable racial
mix. The prevalence
of caries in the district
is amongst the
highest in the country,
with a mean dmft
among 5-year-olds of
2.4.
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported):
The participating practices were
randomly allocated to groups by
the study statistician stratified
by age and caries levels of the
children involved, using
computer generated random
numbers.
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
Oral health (clinical)
results:
Limitations identified
by author:
Each participating
dentist was asked to
provide 10–15 patients
in this category. In the
event many of the
dentists had difficulties
in providing sufficient
patients that met these
criteria and two
practices had to
withdraw from the
study because of this
problem. Several of
the children recruited
were free of caries at
the beginning of the
study and a
considerable
proportion of these
were free from disease
at the final
examination. This
suggests two things.
Firstly, even in a high
caries, low socioeconomic area such as
this in the North West
of England, most
children who go to the
dentist regularly are
not at high risk. It is
also possible that
dentists are not so
Year: 2003
Citation: Blinkhorn,
A.S., et al., A cluster
randomised,
controlled trial of the
value of dental
health educators in
general dental
practice. British
Dental Journal,
2003. 195(7): p.
395-400
Country of study:
England, UK
Aim of Study: The
aim of the study was
to evaluate
the effectiveness
and costs of trusts
seconding salaried
dental health
educators to
selected, cooperating general
dental practices to
control dental caries
in regularly
attending, young
children at risk. This
Setting: General
dental practices in the
West Pennine District
of North-West
England.
Location (urban or
rural): West Pennine
District of North-West
England
Report how confounding
factors were minimised:
[quality assessment]
Stratification by age and caries
levels
Programme/Intervention
description:
What was delivered: Prior to
randomisation: patients and
parents initially seen by a dental
hygienist, parents dental health
knowledge assessed through
questionnaire, study organiser
observed mothers brushing their
children’s teeth.
Dental health counselling in
toothbrushing given to the
parents, including the use of
appropriate fluoride toothpaste,
Outcome name:
Caries levels
Outcome definition:
Mean dmft in
deciduous molars and
canines. Analyses were
conducted at the level
of both teeth and
surfaces, including and
excluding early,
decalcified lesions.
Outcome measure:
Exam
Outcome measure
validated: NR
Unit of measurement:
dmft
Time points
measured: Beginning
and end of study (only
end results reported)
Outcome name:
Plaque scores
Outcome definition:
The presence of plaque
- whether plaque is
Caries levels (dmft) at
final examination
(after 2 years)
Mean (SD):
Total sample:
Baseline: NR
End point: NR
Intervention
group(s):
Baseline: NR
End point: 2.65
(2.56)
Control group(s)
Baseline: NR
End point: 3.22
(2.85)
Coeff (SE) 0.55 (0.44)
(Intracluster
correlation coefficient
= 0.101, design effect
Deff = 1.8)
P value 0.21
Attrition details:
Intervention group:
35 children (20%)
didn’t complete the
follow-up
76
Oral Health: Approaches for general practice teams on promoting oral health
Study details
included, in addition
to reducing the
prevalence of caries
in children, the
ability of such a
programme to
improve the dental
health knowledge,
attitudes and
toothbrushing skills
of the parents of
these children.
Study Design: 2
cell, parallel group,
cluster randomised,
controlled clinical
trial.
Quality Score (++,
+, or -): +
External
Validity(++, +, or -):
+
Population and
setting
Sample
characteristics:
Age: 1-6 years of
age.
Mean age:
Control group = 4.2
Intervention group =
4.1
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR but
area has a
considerable racial
mix
Religion: NR
Place of residence:
West Pennine District
of North-West
England
Occupation: NR
Education: NR
Socioeconomic
position: The district
is made up mainly of
the 2 boroughs of
Tameside and
Oldham, both
relatively
economically
disadvantaged.
Social capital: NR
Eligible population
Method of allocation to
intervention/control
and sugar control over the
course of 2 visits. Included
hands-on demonstrations of
how to clean a small child’s
teeth together with a free issue
of toothpaste and a small
toothbrush, the analysis of 24
hour diet records and
supporting commercial dental
health education leaflets.
Parents and children were
recalled every 4 months over 2
years to reinforce the
counselling and to issue more
toothpaste and toothbrushes
when appropriate.
The same questionnaire was
administered at the end of the
2-year period and toothbrushing
skills were monitored, and an
examination carried out (as at
baseline).
Theoretical basis: N/A
By whom: Study organiser – a
hygienist/therapist with an MSc
in Dental Practice undertook
counselling and administered
questionnaire
An independent experienced
dental epidemiologist examined
all the children at the end of the
study
To whom: Patients (children)
and parents
How delivered: Counselling,
Outcome definitions
and method of
analysis
present at the final
examination (yes or no)
Outcome measure:
Exam
Outcome measure
validated: NR
Unit of measurement:
Number and
percentage of children
Time points
measured: End of
study (after 2 years)
Outcome name:
Dental health
knowledge and
attitudes of parents
Outcome definition:
Number of times
toothbrushing per day,
amount of toothpaste
used, how to brush
child’s teeth, snacking
habits
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Number and
percentage of children
Time points
measured: Start
(baseline) and end
(after 2 years) of study
Results
Notes by review team
Control group: 28
children (17%) didn’t
complete the follow-up
skilled at selecting
from their regular
attenders those who
will get further caries
over the next 2 years.
If either or both of
these concepts are
true, then any
substantive scheme
based on this model
would suffer by
including a proportion
of children who were
not at ‘high risk'.
Because of this it
would seem inefficient
to spend the time of a
skilled dental health
educator counselling
selected parents.
Plaque scores:
whether there is
plaque present at final
examination
Plaque free % (n):
Total sample:
Baseline: NR
End point: NR
Intervention
group(s):
Baseline: NR
End point: 47% (65)
Control group(s)
Baseline: NR
End point: 39% (52)
Although this
difference of 8% was
in favour of the
intervention group
children it was not
large enough to be
statistically significant
(GEE coefficient –0.35
(SE = 0.25), P = 0.16).
Attrition details:
Intervention group:
35 children (20%)
A further problem
encountered at the
beginning of the study
was to persuade the
mothers to attend the
practices for separate
appointments for
dental health
counselling. The
logistics of the study
made it practically
impossible for the
dental health educator
to be present at the
practice when the
77
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area): The
sample size
calculation was based
on detecting a
reduction in the
proportion of children
with a caries
increment >1 from
0.50 to 0.25. A
sample size of an
average of 10 children
in 15 clusters per
study group had
greater than 90%
power to detect this
reduction assuming
an intra-class
correlation coefficient
of 0.05. In the event,
33 practices were
chosen; however,
three had to withdraw,
2 because they were
unable to provide at
least 10 patients who
fitted the criteria and
one because the
practice was planning
a refit.
demonstrations, leaflets
When/where: Dental practices
in West Pennine District of
North-West England
How often: Every 4 months
How long for: 2 years
Practices volunteered
Control/Comparator
description:
What was delivered: The
control group parents and
children were seen only once at
the beginning of the study,
when they were given
toothbrushing instruction and a
tube of fluoride toothpaste.
The same questionnaire was
administered at the end of the
2-year period and toothbrushing
skills were monitored, and an
examination carried out (as at
baseline).
By whom: Study organiser – a
hygienist/therapist with an MSc
in Dental Practice administered
questionnaires.
An independent experienced
dental epidemiologist examined
all the children at the end of the
study
To whom: Patients (children)
and parents
How delivered: Toothbrushing
instruction
When/where: Dental practices
Outcome definitions
and method of
analysis
Outcome name:
Toothbrushing skills
Outcome definition:
Whether children
brushed their own teeth
or whether parents
brushed their children’s
teeth and how.
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Number and
percentage of children
Time points
measured: Start
(baseline) and end
(after 2 years) of study
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders):
The children were
clustered within the unit
of randomisation, the
general dental
practices. The crosssectional caries data in
Results
Notes by review team
didn’t complete the
follow-up
Control group: 28
children (17%) didn’t
complete the follow-up
appropriate children
attended for their
regular inspections, so
separate appointments
on a specific session
were required. This led
to many broken
appointments,
particularly at the
beginning, rendering
the cost per visit
expensive.
Behavioural results:
Dental health
knowledge and
attitudes of parents:
results after 2 years
Correct answers to
questionnaire: %
(n/out of n)
How often should a
child’s teeth be
brushed:
Intervention:
End point: 80%
(n=106/132)
Control:
End point: 78%
(n=90/116)
What type of brush is
best for a young child:
Intervention:
End point: 98%
(130/132)
Control:
End point: 98%
(114/116)
How much toothpaste
should be placed on
No attempt was made
to define what
happened on an
everyday basis in the
home environment.
There is little doubt
that giving information
on diet and teaching
toothbrushing skills to
the mothers in the test
group rendered them
more knowledgeable
and skilful, but whether
this translated into
everyday routines at
home is open to
question.
2 years may be too
short to expect to reap
the benefits of this
concentrated
educational
78
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
to take part and were
asked to provide
between 10–15
patients, 1–6 years of
age.
in West Pennine District of
North-West England
How often: Once at the
beginning of the study (exam
and questionnaire also at the
end)
How long for: 2 years
At the beginning of
the study, 30
practices provided
269 parents who
contributed 334
children.
State if eligible
population is
considered by the
study authors as
representative of the
source population:
Unclear – practices
volunteered to take
part
Inclusion Criteria:
In order to be
included, each
practice had to accept
the nature of the
study, had to have
premises which would
allow the study to take
place in a suitable
environment, had to
have a well organised
recall system and no
stated dental health
Sample size at baseline:
Cluster:
Total sample N = 30 practices
Intervention group N = 15
practices
Control Group N = 15 practices
Individuals:
Total sample N = 269 parents,
334 children
Intervention group N = 138
parents, 172 children
Control Group N = 131
parents, 162 children
Baseline comparisons (report
any baseline differences
between groups in important
confounders): No significant
imbalances between the 2
groups (gender not specified)
Study sufficiently powered
(power calculations and
provide details):
The sample size calculation was
based on detecting a reduction
Outcome definitions
and method of
analysis
both groups were
compared using
generalised estimating
equations (GEE) with
identity link and
exchangeable
correlation coefficients
to control for the effects
of clustering. This was
carried out separately
for both the baseline
data collected by the
study organiser and the
final examinations
recorded by the
independent dental
epidemiologist. The
baseline data were
used solely to allocate
practices to groups. As
the study organiser
was aware of the group
allocation during the
course of the study it
was not appropriate to
base the results on the
calculation of
increments as this may
have resulted in bias.
Differences between
the parents’ knowledge
of and attitudes
towards dental health
and their toothbrushing
skills in the test and
Results
Notes by review team
the brush:
Intervention:
End point: 70%
(92/132)
Control:
End point: 53%
(62/116)
programme.
How much fluoride
should the paste
contain:
Intervention:
End point: 80%
(105/132)
Control:
End point: 6%
(7/114)
How should you brush
your child’s teeth:
Intervention:
End point: 64%
(85/132)
Control:
End point: 32%
(37/116)
When is it best to give
sugary foods and
drinks to young
children:
Intervention:
End point: 91%
(119/131)
Control:
End point: 66%
Limitations identified
by review team:
Population may not be
representative of the
source population as
practices volunteered
to participate.
Randomisation by
practice (cluster) but
results/analysis by
individuals.
For toothbrushing skills
the drop out rate in the
control group was high
(46%).
Evidence gaps:
NR
Source of funding:
The National Primary
Dental Care Research
and Development
Programme funded the
investigation.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
policy.
in the proportion of children with
a caries increment >1 from 0.50
to 0.25. A sample size of an
average of 10 children in 15
clusters per study group had
greater than 90% power to
detect this reduction assuming
an intra-class correlation
coefficient of 0.05. In the
event, 33 practices were
chosen; however, 3 had to
withdraw, 2 because they were
unable to provide at least 10
patients who fitted the criteria
and one because the practice
was planning a refit.
The children were
required to have good
general health, to
attend (the dentist) on
a regular basis, to
have some caries
experience, and in the
opinion of their
dentist, to be at risk to
caries over the next 2
years. Some families
had more than one
child who fitted the
criteria, and so there
were more children
than parents involved.
Exclusion Criteria:
NR
% of selected
individuals agreed
to participate: 3 out
of 33 practices
withdrew (9%)
Potential sources of
bias:
None reported –
examiners were
unaware of group
allocation to eliminate
bias
Outcome definitions
and method of
analysis
control groups were
compared at the
beginning and end of
the study using the
same GEE approach
with logit link function.
Results
Notes by review team
(77/116)
Which four of the
following foods cause
most decay in
children:
Intervention:
End point: 32%
(42/132)
Control:
End point: 6%
(7/116)
How important is
decay in milk teeth:
Intervention:
End point: 79%
(104/132)
Control:
End point: 72%
(83/116)
If your child had decay
in a baby tooth what
treatment would you
want:
Intervention:
End point: 57%
(75/132)
Control:
End point: 49%
(57/116)
Attrition details:
Intervention group: 6
parents didn’t
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
complete the follow-up
(4%)
Control group: 15
parents didn’t
complete the follow-up
(11%)
Toothbrushing skills:
after 2 years % (n):
Position of parent in
relation to child
(behind/any other):
Intervention:
End point: 75%
(88/117)
Control:
End point: 14%
(10/71)
Parent’s method of
holding toothbrush
(finger grip/any other):
Intervention:
End point: 97%
(113/117)
Control:
End point: 21%
(15/71)
Amount of toothpaste
placed on brush
(small pea/any other):
Intervention:
End point: 99%
(116/117)
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Control:
End point: 18%
(13/71)
Whether the front and
back teeth were
brushed (yes/no):
Intervention:
End point: 95%
(111/117)
Control:
End point: 21%
(15/71)
Mean length of time
teeth were brushed (in
seconds):
Intervention:
End point: Mean = 30
Control:
End point: Mean = 25
Attrition details:
Intervention Group:
21 parents didn’t
complete the follow-up
(15%)
Control Group: 60
parents didn’t
complete the follow-up
(46%)
Cost: Each 2-hour
session to counsel ten
parents cost £39.37
(including travel and
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
materials).
Conclusion:
The model tested of
seconding a qualified
dental health educator
to general dental
practices to counsel
mothers of regularly
attending, at-risk,
young children failed
to reveal a substantial
improvement in dental
health over a 2-year
period. However,
there were clear
benefits in relation to
dental health
knowledge, attitudes
and toothbrushing
skills among these
mothers.
On the basis of this
result, Primary Care
Trusts should carefully
consider value for
money before
adopting such a
strategy to improve
the dental health of
young children within
their localities.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: George
Boundouki, Gerry
Humphris, Anne
Field
Source
Population(s):
UK but no additional
information other than
that reported in
setting.
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): Sessions were
designated randomly into leaflet
(experimental) and non-leaflet
(control) groups (p.72 para 3).
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
Behavioural results:
Limitations identified
by author:
Conclusions from
these studies were
limited because they
assessed effects soon
after the time patients
were first exposed to
the written information.
(p.72 para 2)
Year: 2004
Citation:
Boundouki, G., G.
Humphris, and A.
Field, Knowledge of
oral cancer, distress
and screening
intentions: longer
term effects of a
patient information
leaflet. Patient
Education and
Counselling, 2004.
53(1): p. 71-7.
Country of study:
UK
Aim of Study:
Study aim was to
determine the
influence of a
patient information
leaflet (PIL) on
mouth cancer to
improve knowledge,
reduce distress and
increase intention to
accept a mouth
Setting: 2 dental
surgeries were
chosen. The first was
drawn from an inner
city area and the
second from a
suburban area (p.72
para.3).
Location (urban or
rural): Both clinics
were urban.
Report how confounding
factors were minimised:
[quality assessment] Allocation
by session was adopted
specifically to prevent
contamination whereby control
patients unwittingly receive
access to the leaflets by
accident (p.72 para 3).
Sample
characteristics:
Age (mean): 47.4
Sex (no. of females):
187 (59%)
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education (mean
year left school):
Programme/Intervention
description:
What was delivered: Patients
who agreed to participate were
given the questionnaire to
complete while waiting for their
dental appointment. In the
experimental group patients
were provided with the mouth
cancer leaflet and instructed to
read it. They were asked to
return the PIL to the researcher
prior to completion of the
questionnaire to prevent
referring to it while answering
Outcome name: 1)
Knowledge of mouth
cancer (p.72 para 4)
Outcome definition:
N/A.
Outcome measure:
Consists of 36
dichotomous questions
with respondents gave
true/false replies.
Correct scores were
then summed (p.72
para 4)
Outcome measure
validated: Yes – the
scale has criterion
validity (p.72 para 4)
1) Knowledge of
mouth cancer
Mean scores with
standard deviations in
brackets and MannWhitney U results
below (all results from
p.74 Table 2).
Intervention group(s):
Baseline: 31.05 (3.53)
8 weeks: 30.26 (2.86)
Control group(s)
Baseline: 28.08 (3.25)
8 weeks: 29.04 (2.57)
Baseline - leaflet v
non-leaflet:
MWU z: -7.70
P value: 0.001
Unit of measurement:
Score on a 0-36 unit
knowledge scale (p.72
para 4)
8 weeks - leaflet v
non-leaflet:
MWU z:-4.04
P value: 0.001
Time points
measured: Baseline
and 8 weeks follow-up
2) Mouth screen
distress scale
Outcome name: 2)
Mean scores with
While the paper
showed a lack of
diminution of the effect
of the leaflet over the 8
week period the
patients were
expecting a follow up
contact in the form of a
further questionnaire.
(p.75 para 4)
The findings are
restricted to the 2
dental practices
sampled. A deliberate
attempt had been
made to select
practices from different
surroundings
(suburban and innercity). In addition, forty
percent of participants
were lost at follow-up.
The participants who
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Population and
setting
Method of allocation to
intervention/control
screen over a 2month period
(abstract).
17.8
Socioeconomic
position: NR
Social capital: NR
questions. (p.73 para.2)
Theoretical basis: N/A
By whom: The researcher (one
of the authors) (p.73 para.2)
To whom: Consenting patients
How delivered: Leaflet. The
design quality of the leaflet was
assessed adopting the new
medical information design
assessment scale (MIDAS). The
leaflet obtained a total score of
11 from a possible maximum of
13. (p.72 para.3)
When/where: In the waiting
area of the dental clinic (p.73
para.2)
How often: Just once
How long for: During one day
only
Study Design:
Parallel RCT (p.72
para.3 and p.73 Fig
1)
Quality Score (++,
+, or -): +
External
Validity(++, +, or ): +
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): the
researcher
approached patients
in the waiting areas of
the dental surgeries
and explained the
study and asked for
consent to participate
(p.73 para.2).
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR – although
decision to conduct
the research in 2
surgeries in areas
with different socioeconomic
characteristics will
help.
Control/Comparator
description:
What was delivered: Patients
were given a questionnaire to
complete.
By whom: The researcher (one
of the authors) (p.73 para.2)
To whom: Consenting patients
How delivered: N/A
When/where: In the waiting
area of the dental clinic (p.73
para.2)
How often: Just once
How long for: During one day
only
Outcome definitions
and method of
analysis
Mouth screen distress
scale (p.72 para.5)
Outcome definition:
N/A.
Outcome measure:
Three items using the
common stem: “How do
you feel about having a
check for mouth
cancer?” Each item had
a five point rating scale
based on perceived
levels of anxiety, worry
or concern. The scales
were then summed on
a scale ranging from
low to high distress
(p.72 para.5).
Outcome measure
validated: Yes – the
Cronbach alpha from a
separate sample of
university students was
0.91 (p.72 para.5).
Results
Notes by review
team
standard deviations in
brackets and MannWhitney U results
below (all results from
p.74 Table 2).
responded at 2
months were not fully
representative of the
initial baseline sample
with fewer non-regular
dental attendees and
smokers, hence
caution is required
when generalising the
results (p.76 para.2).
Unit of measurement:
Score on a scale
ranging from 3 to 15.
3) Intention to accept a
mouth cancer screen
Time points
measured: Baseline
and 8 weeks follow-up
Outcome name: 3)
Intention to accept a
mouth cancer screen
Intervention group(s):
Baseline:4.48 (2.20)
8 weeks:4.46 (2.10)
Control group(s)
Baseline:4.92 (2.22)
8 weeks:4.94 (2.47)
Baseline - leaflet v
non-leaflet:
MWU z:-2.57
P value: 0.01
8 weeks - leaflet v
non-leaflet:
MWU z:-1.97
P value: -0.049
Mean scores with
standard deviations in
brackets and MannWhitney U results
below (all results from
p.74 Table 2).
Intervention group(s):
Limitations identified
by review team:
The source population
isn't really specified.
Although the research
is plainly in the UK
there is no information
on where exactly.
Furthermore while the
Authors selected 2
dental clinics - one in a
suburban and one in
an inner city area
which should improve
representation by
socio-economic group.
Research in a rural
area does not seem to
have been considered.
16% (82) patients who
were invited refused to
participate and the
refusers did differ
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Population and
setting
Method of allocation to
intervention/control
Sample size at baseline:
Inclusion Criteria:
there does not appear
to be any inclusion
criteria.
Exclusion Criteria:
there does not appear
to be any exclusion
criteria.
% of selected
individuals agreed
to participate: 84%
of the 526 patients
invited to participate
consented to take
part. 82 patients who
were invited refused
to participate. The
refusal group did not
differ significantly from
the participants by
gender but did differ
significantly by age
(older patients were
more likely to refuse)
(p.73 para.5).
Potential sources of
bias:
Total sample N = 418 (444
consented but 26 did not return
sufficiently complete data for
analysis)
Intervention group N = 217
Control Group N = 201
(p.73 Fig 1 and para.7)
Baseline comparisons (report
any baseline differences
between groups in important
confounders): No comparison
on statistical testing showed
significant non-equivalence
(p<0.1) between the intervention
and control groups.
Study sufficiently powered
(power calculations and provide
details): A power analysis
showed that a sample size of
143 in each group would have
80% power to detect difference
in means of a single question
assuming a common standard
deviation of three using a 0.05
significance level.
Approximately 500 patients
were planned to enter the study
allowing for a 40% attrition rate
(p.73 para.3).
Outcome definitions
and method of
analysis
(p.72 para.6)
Outcome definition:
N/A.
Outcome measure:
Assessed with 2
questions: ‘how likely
would you agree to
have an oral health
screen to check your
mouth for cancer’ and
‘how likely would you
refuse to have a check
for oral cancer’. A 7
point rating scale was
employed for both
items and coded 1
‘extremely unlikely’ to 7
‘extremely likely’ (p.72
para.6). Both questions
were then summed.
Outcome measure
validated: NR
Unit of measurement:
Score on a scale
ranging from 2 to 14.
Time points
measured: Baseline
and 8 weeks follow-up
Outcome name: 4)
Re-reading of the
mouth cancer leaflet
Outcome definition:
Patients in the
Results
Notes by review
team
Baseline:12.44 (2.12)
8 weeks:12.79 (1.87)
significantly from
participants by age.
Control group(s)
Baseline:11.75 (2.69)
8 weeks:12.25 (2.26)
Allocation was by
session so it was not
truly random although
this was designed to
limit contamination
which would have
been a significant risk
given the intervention
was a leaflet.
Baseline - leaflet v
non-leaflet:
MWU z:-2.24
P value: 0.025
8 weeks - leaflet v
non-leaflet:
MWU z:-2.48
P value: 0.013
4) Re-reading of the
mouth cancer leaflet
Of the 162
respondents who
replied (out of a
possible 169) 31% had
re-read the leaflet.
Knowledge
remained stable
(mean change score =
0.38, median =0.7,
S.D. = 3.59) in the
patients that reviewed
the leaflet at least
once following the
initial introduction at
baseline (z =−1.22, P
It is not absolutely
clear how participants
in the intervention
group were prevented
from filling-in some of
the questionnaire
while they possessed
the leaflet. The fact
that they needed to
hand the leaflet in
before the
questionnaire does not
guarantee against this
possibility.
The researcher (who
was also the author)
approached each
patient so they would
have known the
allocation. Therefore
there was no blinding.
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
intervention group were
asked if they read the
leaflet again in the
weeks between
receiving the leaflet and
prior to completing the
follow-up questionnaire
(p.75 para.2).
Outcome measure:
Question response
Outcome measure
validated: NR
Unit of measurement:
% who read leaflet
Time points
measured: Period
between baseline and 8
week follow-up
Results
Notes by review
team
= 0.22) whereas those
who had read the
leaflet only once in the
waiting room, were
found to have
deteriorated in their
knowledge (mean
change score = −1.33,
median = −1.3, S.D. =
3.34; z = −4.26, P <
0.001). (p.75 para.2)
Evidence gaps:
Research is needed
over the longer-term.
The question remains:
To what extent are
these improvements,
gained from access to
the leaflet, sustained
over time? (p.72
para.2)
The independent
variables of age
(p=0.001), smoking
status (p=0.03) and
knowledge (p=0.03)
were found to
significantly predict rereading of the leaflet.
(p.75 para.2)
Method of analysis
(indicate if ITT or
completer analysis was
used and if adjustments
were made for any
baseline differences in
important
confounders):
Attrition details:
Indicate the number
lost to follow up and
whether the proportion
lost to follow-up
differed by group (i.e.
intervention vs control)
The Mann-Whitney U
test was used to test
the significance of
comparisons between
the intervention and
control group. (p.74
The 8 week trial
follow-up resulted in
317 useable
questionnaire replies
(60% response rate),
including 169 in the
Source of funding:
Zila® sponsored the
project and published
the leaflet (p.72
para.3).
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Table 2)
A multiple logistic
regression was used to
predict re-reading of
the mouth cancer
leaflet. Independent
variables were: age,
gender, smoking
status, intention to
accept screen, distress,
alcohol consumption
and knowledge of
mouth cancer. p.75
para.2)
There is no reference
to ITT being used.
Results
Notes by review
team
intervention group and
148 in the control.
(p.73 Fig 1 and para.7)
Categorical variables:
gender, practice, selfreported alcohol
consumption, receipt
of leaflet and
continuous variables
including age, and the
3 outcome variables
were not significantly
different between
patients who were
followed up or lost to
the study. Patients
who smoked were less
frequent in the follow
up sample (17%)
compared with nonresponders (26%, χ2=
4.26, P = 0.04). In
addition, follow up
patients claimed to be
regular 6-month
attendees of the
dentist more frequently
than non-responders
(93 and 80%,
respectively, χ2=
17.56, P = 0.001).
(p.73 Fig 1 and para.7)
Conclusion:
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
There were 3 major
findings. First, a leaflet
about mouth cancer
given to patients
attending primary
dental care services
resulted in measurable
benefits 2 months
later. These benefits
included an increase
in knowledge about
mouth cancer, a
borderline reduction in
distress about having
a mouth cancer screen
and an increase in the
likelihood of accepting
such a screen. (p.75
para.3)
Second, the study
found a lack of
diminution of the effect
of the leaflet after an 8
week period. (p.75
para.4)
Thirdly, patients who
claimed that they
revisited the leaflet by
re-reading it
maintained their level
of knowledge,
whereas the
remainder of the
leaflet group (the
89
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
majority) who did not
re-read the leaflet
suffered a significant
drop in knowledge.
There may be an
opportunity therefore
to ‘maximise’ the effect
of the mouth cancer
leaflet by
recommending that it
is re-read. (p.75
para.5)
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
Notes by Review Team
Author: Brocklehurst,
P. et al
Study design: A qualitative
programme evaluation using
semi-structured interviews
Population the sample was
recruited from: Local
clinicians who had been
involved in the planning and
running of the “Baby Teeth
DO Matter” programme
(p.243)
Brief description of method
and process of analysis
[including analytic and data
collection technique]:
Limitations identified by
author:
How sample was recruited:
Local clinicians who had
been involved in the
planning and running of the
“Baby Teeth DO Matter”
programme were contacted
by email and invited to
participate (p.243)
The researchers immersed
themselves in the data by initially
reading and re-reading the
transcriptions before generating
codes. Overarching themes were
developed from the coded
transcripts by organising them
into clusters based on the
similarity of their meaning. These
were then checked against the
coded extracts and the raw data
to ensure that they formed a
coherent pattern and were
representative of what the
participants were trying to
convey. The coding process was
undertaken manually. Specific
examples were selected to create
clear definitions for the coding
frame. (p.243/246)
Year: 2013
Citation: Brocklehurst,
P., C. Bridgman, and
G. Davies, A
qualitative evaluation
of a Local Professional
Network programme
"Baby Teeth DO
Matter". Community
Dental Health, 2013.
30(4): p. 241-8.
Country of study:
Quality Score (++, +,
or -): +
Research aims,
objectives, and questions:
The objective of this study
was to use a qualitative
approach to examine the
perceptions of dentists who
led a health promotion
programme entitled “Baby
Teeth DO Matter”. (abstract)
The aim of the research was
to qualitatively explore the
role of clinical leadership in
the context of the GM
shadow LPN and Phase 1
and 2 of the “Baby Teeth
DO Matter” to understand
the impact that empowering
local clinicians played in the
development and running of
the programme. (p.242,
para.6)
Theoretical approach
[grounded theory, IPA
etc]: NR
State how data were
collected:
What method(s): A set of
opening questions were
developed for the semi-
How many participants
recruited: 6
Sample characteristics:
Age: NR
Sex: NR
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: Greater
Manchester
Occupation: Clinicians
Education: NR
Socioeconomic position:
NR
Social capital: NR
Inclusion criteria: Clinicians
Thematic analysis and coding
took place.
Key themes and findings
relevant to this review [with
illustrative quotes if available]
(p.246)
8 codes under 3 themes were
generated:
Theme 1: Impact
Limitation of the programme
(rather than the evaluation):
- the use of financial incentives
to drive the programme forward
and encourage adoption
(participating practices received
£25 for first appointment and
then £75 should the child return
for a follow-up appointment after
three months) (p.247, pa.3)
Limitations identified by
review team:
Participants’ characteristics are
not described (except for
occupation and area of study).
Only one method used
(interviews).
Limitations of the evaluation
study not identified by author.
Evidence gaps and/or
recommendations for future
research:
Another key aspect that arose
from the results of the
evaluation was the importance
of keeping the approach and
messages simple and also
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Study Details
Research Parameters
structured interviews from
existing research on
leadership (Hoffman et al
2011; Judge et al 2004) and
the NHS leadership
framework. In accordance
with Carter and Henderson’s
guidance (2007), these were
open-ended questions and
investigated the views and
experiences of participating
GDPs in the “Baby Teeth
DO Matter” programme and
shadow LPN more broadly.
The topic guide was
developed further in parallel
with the interviews to
facilitate constant
comparison analysis. The
interviews were recorded
digitally, and transcribed
verbatim by one researcher.
It was determined in
advance that the interviews
would continue until
saturation had been
reached. The saturation
point was assessed by the
transcriber when no new
information was generated
from the analyses. (p.243)
By whom: Researchers
What setting: General
Dental Practice
Population and Sample
Selection
who had been involved in
the planning and running of
the programme
Outcomes and Methods of
Analysis
Code 1 – success of the project:
All of the participants stated that
the programme had been
successful.
Exclusion criteria: NR
Code 2 - Down-stream to upstream:
The involvement in the
programme had shifted the
perspective of GDPs: “…general
dental practitioners have never
really had an opportunity to go
out into the community and use
their own initiative of how to
actually bring patients in…”
Notes by Review Team
ensuring good communication
through the command and
control structure. This will be a
challenge to LPNs in the future
as they seek to strategically
lead their local clinicians who
have a broad range of clinical
interests. (p.247, para.4)
Source of funding: NR
Theme 2: Components of
success
Code 3 – Importance of
“Clinically Led and Clinically
Owned”:
The idea of a locally led
programme was widely viewed
positively: “…they know what’s
happening on the ground level,
they know what’s possible and
what’s not possible, what will
work well and what won’t”
Code 4 – Keeping the approach
simple:
All participants felt that the
messages had to be simple
(given the broad geographic and
organisational scope of the
programme): “ …when you’ve got
simple messages, simple ideas,
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Study Details
Research Parameters
When: NR
Population and Sample
Selection
Outcomes and Methods of
Analysis
simple models if you go out and
deliver it’s a lot more effective
and efficient”
Notes by Review Team
Code 5 - Importance of
networking:
The structure used in the
programme was based on
“Securing Excellence in
Commissioning Primary Care”
(NHS Commission Board, 2012)
and proved to be an important
component of its success:
“… I think it’s been a success in
using general practitioners and
them radiating it out to other
practitioners and getting them
involved”
Code 6 – Importance of Dental
Public Health:
Dental Public Health input was
considered to be important.
Code 7 - Importance of task and
finish:
The task and finish resources
were also critical: “…admin was a
very important role…we need
posters, we need banners…”
Theme 3: The future
Code 8 – Threats to the future of
the Local Professional Network:
A significant concern amongst
the clinicians after the
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
programme had been delivered
was whether the LPN would be
allowed to continue its work going
forward, or whether it would be
re-organised by the emerging
new NHS structures:
Notes by Review Team
“…different bodies and parties
with separate agendas all
wanting to maybe take over that
or infiltrate…”
Conclusions:
(p.247)
“Clinically Led” and “Clinically
Owned” projects create and
empower community-facing
practitioners. They also build
capacity and develop personal
skills in line with the fundamental
principles of the Ottawa Charter.
Critical for success in
programmes of this nature are:
Dental Public Health input; clarity
of communication within the
network; and, the necessary
resources to support both
clinicians and the project
management costs.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
Author: Clarkson,
J.E., Young, L.,
Ramsay, C.R.,
Bonner, B.C., and
Bonetti, D.
Source
Population(s):
Dentate adults who
had already made an
appointment for a
routine check-up and
had proving of the
gingiva not
contraindicated at the
time of the
appointment.
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported):
A patient-randomised
controlled trial and a cluster
RCT on the same intervention
were conducted
independently.
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective or
otherwise validated):
Oral health (clinical)
results:
Setting: Primary care
setting in Scotland
Report how confounding
factors were minimised:
Reported change to a
powered or manual
toothbrush and if hygiene
advice was given to the
control group at baseline
appointment.
Limitations
identified by
author:
The authors state
that the lack of
blinding might
explain why only
the cluster RCT
showed a
statistically
significant effect of
the intervention on
the clinical
outcomes.
Year: 2009
Citation: Clarkson,
J.E., et al., How to
influence patient oral
hygiene behaviour
effectively. Journal of
Dental Research,
2009. 88(10): p. 9337.
Aim of Study: To
compare the
effectiveness of an
evidence-based
intervention, framed
with psychological
theory, with routine
care, in improving
patients’ oral hygiene
behaviour.
Additionally, the
study explored
contamination effects
of different trial
methodologies, i.e.
how likely it is that
the control group
Sample
characteristics:
Age:
Patient RCT: mean
(SD)
Control: 36.5 (12.9)
Intervention: 38.5
(14.7)
Cluster RCT: mean
(SD)
Control: 36.5 (14.0)
Intervention: 34.9
(12.7)
Sex:
Patient RCT: Female:
n (%)
Programme/Intervention
description:
Intervention was the same for
both RCTs
What was delivered: Our
intervention included all of
these elements [outlined in
theoretical approach below] to
create a complete, evidence
based package as the most
likely means of effectively
influencing the oral hygiene
behaviour of patients within a
Oral health (clinical)
Outcome name: % of
surfaces with bleeding
Outcome definition: We
used the Silness and Loe
index to calculate the
percentage of surfaces
with plaque and showing
gingival bleeding on
gentle probing.
Outcome measure
validated: NR
Time points measured:
Baseline and 8 weeks
(plus or minus 2 weeks)
for both trials
Unit of measurement:
Percentage
Outcome name: % of
surfaces with plaque
Outcome definition: We
used the Silness and Loe
index to calculate the
percentage of surfaces
with plaque and showing
gingival bleeding on
% of surfaces with
bleeding (Patient
RCT): Mean [SD]
Intervention: 15.5 [16.7]
Control: 21.8 [25.4]
Mean difference [95%
CI]: -3.5 [-11.8, 4.8]
P = 0.404
% of surfaces with
bleeding (Cluster
RCT): Mean [SD]
Intervention: 21.6 [20.6]
Control: 26.0 [26.3]
Mean difference [95%
CI]: -7.4 [-15.0, 0.2]
P = 0.057
% of surfaces with
plaque (Patient RCT):
Mean [SD]
Intervention: 27.6 [19.8]
Control: 31.2 [23.5]
Mean difference [95%
CI]: -4.5 [-12.7, 3.7]
P =0.279
% of surfaces with
plaque (Cluster RCT):
Mean [SD]
Intervention: 31.2 [26.4]
Control: 54.0 [31.1]
Limitations
identified by
review team:
It is not clear how
participants were
recruited or
whether the
characteristics
outlined in Table 1
reflect the source
population. Only 6
of the 93 dentists
invited did not
participate while
57% of invited
patients agreed to
participate.
However it is not
clear whether there
were any
95
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
also received the
intervention, by
testing the
intervention in 2 trials
with different
randomised designs.
Control: 84 (57.5)
Intervention: 95 (65.5)
primary care environment.
The evidence-based
intervention (a powered
toothbrush and behavioural
advice on timing, method and
duration of toothbrushing) was
framed to target oral hygiene
self efficacy (social cognitive
theory) and action plans
(implementation theory). The
content and the delivery of the
intervention were
standardised as a series of
steps. Social cognitive theory
was applied using a ‘Tell,
Show, Do’ approach of
dentists giving advice to
patients. At the end of the
advice patients were given a
toothbrush to take away with
them. Implementation theory
was applied by asking
patients when was the best
time for them to use their
toothbrushes and by the
dentist eliciting an action plan.
gentle probing.
Outcome measure
validated: NR
Time points measured:
Baseline and 8 weeks (+/2 weeks) for both trials
Unit of measurement:
Percentage
Mean difference [95%
CI]: -16.7 [-25.7, -7.7]
P =<0.001
differences
between the
demographics of
the study
population (Table
1) and those of the
eligible population
(not reported). No
information
provided on exactly
how patients were
randomised.
Information may be
available in the
appendices which
we do not have.
Dentists in the
patient RCT were
aware of each
patient's group
allocation. It was
also theoretically
possible for dentists
to have
manipulated the
results in the
cluster RCT. Less
than 20% (19% and
16%) dropped out
of patient RCT and
there was no
significant
difference in any
baseline measure
between patients
who did or did not
Study Design:
Parallel RCT and
cluster RCT on the
same intervention
were conducted
independently.
Quality Score (++,
+, or -): +
External Validity
(++, +, or -): +
Cluster RCT: Female:
n (%)
Control: 84 (57.5)
Intervention: 95 (65.5)
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Scotland
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement,
class list, area):
Eligible clinicians
were dentists who
spent their first year
after graduation in
Scotland. Eligible
patients were dentate
adults who had
already made an
Theoretical basis: Social
Cognitive Theory (Bandura
1999) which proposes that a
key variable influencing
behaviour is self-efficacy,
assessed by a person’s
confidence in his/her ability to
perform the behaviour.
Behavioural:
Outcome name: Timing
Outcome definition: “On
average how often do you
brush your teeth?”
Outcome measure
validated: NR
Time points measured:
Baseline and 8 weeks (+/2 weeks) for both trials
Unit of measurement:
Score. A correct response
of at least twice a day
was given a score of 1. All
other responses were 0.
Outcome name: Duration
Outcome definition: “On
average how long do you
take to brush your teeth?”
Outcome measure
validated: NR
Time points measured:
Baseline and 8 weeks (+/2 weeks) for both trials
Unit of measurement:
Behavioural results:
Timing (Patient RCT):
Mean [SD]
Intervention group: 100
[85.5]
Control group: 83 [71.6]
Odds ratio [95% CI]: 2.8
[1.2, 6.9]
P <0.05
Timing (Cluster RCT):
Mean [SD]
Intervention group: 143
[86.7]
Control group: 158
[78.6]
Odds ratio [95% CI]: 2.1
[1.2, 3.6]
P < 0.01
Duration (Patient
RCT): Mean [SD]
Intervention group: 68
[58.6]
Control group: 51 [44.0]
Odds ratio [95% CI]: 3.3
[1.7, 6.5]
P <0.001
Duration (Cluster
RCT): Mean [SD]
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
appointment for a
routine check-up and
had probing of the
gingiva not
contraindicated at the
time of the
appointment.
Another model is
Implementation Intention
Theory (Gollwitzer, 1999;
Webb and Sheeran, 2004)
which proposes that making
an explicit action plan about
where and when a behaviour
will be performed increases
the person’s likelihood of
performing it.
Score. A correct response
of at least 2 minutes was
given a score of 1. All
other responses were 0.
Intervention group:117
[70.9]
Control group: 91 [45.3]
Odds ratio [95% CI]: 3.0
[1.9, 4.8]
P <0.001
return a
questionnaire.
However drop-out
rate in cluster RCT
was over 20% and
there were many
more drop-outs
form the
intervention group
than from the
control group [Note:
this assumes that
the sentence in 935
para.8 on the return
of questionnaires in
the cluster group is
a mistype]. Most
outcome measures
were patient
reported and there
was no indication
that they had been
validated. The
paper outlines the
required number of
dentists and
patients needed for
80% power for both
a patient and
cluster RCT in
relation to the
clinical outcomes.
However the
number of dentists
and patients in both
trials is a little lower
State if eligible
population is
considered by the
study authors as
representative of
the source
population: NR
Inclusion Criteria:
NR
Exclusion Criteria:
NR
Both of these theories were
used to frame and evidence
based intervention. The best
evidence available suggest
that dentists should provide
chair-side oral hygiene advice
about the method and timing
of toothbrushing, provide or
recommend the use of a
powered toothbrush with a
rotation oscillation action, and
provide instruction in the use
of the toothbrush (e.g. Kay
and Locker 1998; SIGN 2002;
Marinho et al 2003; Robinson
et al 2003).
The study hypothesis was that
an evidence based
intervention, framed with
psychological theory, would
improve patients’ oral hygiene
behaviour.
By whom: Dentist
How delivered:
Outcome name: Method
Outcome definition:
“Usually, when you finish
brushing your teeth, do
you…?”
Outcome measure
validated: NR
Time points measured:
Baseline and 8 weeks (+/2 weeks) for both trials
Unit of measurement:
Score. A correct response
of spit but do not rinse
was given a score of 1. All
other responses were 0.
Outcome name: Oral
Hygiene Self-efficacy
(toothbrushing
confidence)
Outcome definition:
Patients were asked how
confident they were on a
7-point scale: following
advice from their dentist
about brushing their teeth;
brushing their teeth as
often as they should; the
way that they should.
Outcome measure
validated: NR
Method (Patient RCT):
Mean [SD]
Intervention group: 62
[54.9]
Control group: 40 [36.0]
Odds ratio [95% CI]:3.5
[1.8, 6.6]
P < 0.001
Method (Cluster RCT):
Mean [SD]
Intervention group: 105
[65.2]
Control group: 62 [31.2]
Odds ratio [95% CI]:5.3
[3.6, 7.8]
P <0.001
Oral Hygiene Selfefficacy (Patient RCT):
Mean [SD]
Intervention group: 28.3
[5.8]
Control group: 26.7 [5.2]
Mean difference [95%
CI]: 1.5 [0.2, 2.8]
P < 0.05
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
(a) Modes of delivery Chair-side oral
hygiene advice from
Dentist using a “tell,
show, do” model. F
Time points measured:
Baseline and 8 weeks (+/2 weeks) for both trials
Unit of measurement:
Mean score
(b) Framing the health
message,
Positive – patients
asked to clean teeth
in front of dentist, they
are then corrected if
required and once
they are confident
they are praised.
Outcome name:
Planning
Outcome definition:
Patients were asked if
they had plans relating to
duration, timing and
method of toothbrushing.
Outcome measure
validated: NR
Time points measured:
Baseline and 8 weeks (+/2 weeks) for both trials
Unit of measurement:
Score based on Yes=1
and No=2. Scores were
summed.
Oral Hygiene Selfefficacy (Cluster RCT):
Mean [SD]
Intervention group: 28.7
[4.4]
Control group: 27.0 [5.3]
Mean difference [95%
CI]: 0.9 [0.0, 1.8]
P <0.05
than the
requirements.
Furthermore a large
proportion of the
patients droppedout of the clinical
follow-up. Effect
sizes not reported
although odds
ratios available for
dichotomous
outcomes.
(c) Approaches to
present the
information,
Tell – Patient told to
brush twice a day for
2 minutes, using an
electronic toothbrush
and fluoride
toothpaste and to spit
but not rinse.
Show – Dentist shows
toothbrushing
technique
Do – Dentist corrects
patient if necessary
(d) Whether it is
standalone or
incorporated into
Method of analysis:
Analyses were by
intention to treat. Chisquared tests and t-tests
examined baseline
differences between the 2
trials. Intervention effects
were examined with
generalised linear models
(patient RCT) and a
mixed effect model
(cluster RCT) with
analyses adjusted for
Planning (Patient
RCT): Mean [SD]
Intervention group: 2.4
[0.7]
Control group: 1.8 [0.9]
Mean difference [95%
CI]: 0.6 [0.4, 0.7]
P <0.001
Planning (Cluster
RCT): Mean [SD]
Intervention group: 2.5
[0.8]
Control group: 1.9 [0.8]
Mean difference [95%
CI]: 0.6 [0.4, 0.8]
P <0.001
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e. intervention
vs control)
Evidence gaps:
A plausible
explanation is that
dentists in the
intervention arm of
the cluster RCT
were simply more
practiced in
delivering the
intervention, and so
were more
consistently
effective. This may
be an issue to be
explored in future
patient RCTs.
Further
investigation is also
needed to identify
the relative impacts
of the different
elements of the
intervention.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
wider health
messages:
Standalone
(e) Environment in which
health message is
delivered: Dental
clinic
How long for: Approximately
5 minutes
Control/Comparator
description:
What was delivered: The
control group received routine
care, even if that included oral
hygiene advice
By whom: Dentist
Sample size at baseline:
Patient RCT:
Total sample N = 300
Randomised to Intervention
group N = 149
Randomised to Control Group
N = 151
Cluster RCT:
Total sample N = 50
dentists/478 patients
Randomised to Intervention
group N = 244
Randomised to Control Group
N = 234
Outcome definitions
and method of analysis
baseline scores when
available.
Bleeding/plaque scored
were weighted by
numbers of
margins/surfaces per
patient. Outcomes across
the 2 trials were pooled
by standard fixed effect
meta-analysis methods
that weighted by the
standard error of effect
sizes.
Results
Patient RCT: In the
patient RCT the number
of questionnaires not
returned at follow-up
was similar in both
groups (19% v 16%)
[note: not clear which
one is which] with no
significant difference in
any baseline measure
between patients who
did or did not return a
questionnaire.
Cluster RCT: In the
cluster RCT fewer
questionnaires were
returned by the
intervention group (12%
v 31%) but there was no
significant group
difference in any
baseline measure.
Conclusion: A simple
theory-based
intervention delivered
within the constraints of
a primary care
environment was more
effective than routine
care in influencing
patients’ oral hygiene
cognitions, behaviour,
Notes by review
team
Previous studies
have not explored
the cognitive impact
of the use of a
powered
toothbrush.
Nevertheless,
powered or manual,
a toothbrush needs
to be used and
used properly to
improve oral
hygiene. It is
therefore most
likely that a
combination of the
powered
toothbrush,
behavioural advice,
and the theoretical
framing which
produced the
intervention effects.
Source of
funding: Study
was supported by
the Scottish Dental
Practice Based
Research Network
(SDPBRN); NHS
Education for
Scotland (NES);
Dental Health
Services Unit,
University of
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Baseline comparisons
(report any baseline
differences between groups
in important confounders):
Baseline differences are
compared but not commented
on and there no p values to
ascertain statistical
significance. The differences
appear to be minor in all areas
covered which include gender,
smoking behaviour,
toothbrush use and cognitive,
behavioural and clinical
outcomes. The mean bleeding
levels amongst the control
group (32.4% with SD at
25.6%) were slightly higher
than for the intervention group
(27.7% with SD at 27.7).
Outcome definitions
and method of analysis
Results
Notes by review
team
and health.
Dundee; Health
Services Research
Unit, University of
Aberdeen;
University of
Manchester; Chief
Scientist Office of
the Scottish
Government
Executive; and
Gillette Ltd, Oral-B
Clinical Research.
All views expressed
are the authors’
and not necessarily
those of the funding
bodies. The authors
have no competing
interests.
Study sufficiently powered
(power calculations and
provide details):
The paper states that a
patient RCT would require 38
dentists and 10 patients per
dentist for 80% power at a 5%
significance level for a 10%
reduction in bleeding and
plaque to be detected. This
would mean the study
required 380 patients in the
trial but only 300 were
100
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
included so the 80% figure
must not have been met.
Furthermore only 94
participants in the patient RCT
received a follow-up clinical
examination [note: impact on
power is not explicitly stated].
A cluster RCT required 55
dentists and 10 patients per
dentist to give a similar power.
Again this condition wasn’t
quite met as there were 478
patients in the trial as
opposed to 550. Furthermore
only 187 patients in the cluster
RCT received a follow-up
clinical examination [again the
implications for power were
not explicitly stated].
101
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: T.A. Dyer
and P.G. Robinson
Study design: Mixes-method
study comprising:
 a cross-sectional
qualitative research using
semi-structured interviews
of a purposive sample of
10 practice principles.
 a cross-sectional survey of
a practice principal from
very dental practice in
South Yorkshire using a
self-complete
questionnaire (p.45
abstract)
Population the sample
was recruited from:
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
As always, these data
should be interpreted with
care. However the response
rate to the survey (83.4%) is
considerably higher than
average, 57 minimising
sampling error. Also,
analysis of the responses to
the second and third
mailings found respondent
characteristics and
attitudinal data were
comparable, suggesting
minimal non-response bias.
Furthermore the qualitative
and quantitative data
broadly corroborated each
other. However, the extent
to which these findings can
be generalised to other
regions of the UK will also
depend on logical inference
as South Yorkshire has
characteristics that may
distinguish it from some
areas. For example, the
area contains a dental
school where many of the
dentists trained.
Furthermore participants’
attitudes to PCDs may be
related to the expansion of
PCD training programmes at
that school. (p.50 (para 13)
Year: 2006
Citation: Dyer,
T.A. and P.G.
Robinson, General
health promotion in
general dental
practice--the
involvement of the
dental team Part 2:
A qualitative and
quantitative
investigation of the
views of practice
principals in South
Yorkshire. British
Dental Journal,
2006. 201(1): p.
45-51; discussion
31.
Country of study:
England
Quality Score (++,
+, or -): +
Qualitative methods suit topics
such as this where there is
little pre-existing knowledge.
However qualitative research
cannot make quantifiable
generalisations so a crosssectional survey of dentists
was also undertaken. (p.46
para.6)
Research aims, objectives,
and questions:
To investigate the factors that
might influence the provision
of general health promotion
through 7 different health
interventions by dental teams
in general dental practice.
(p.45 abstract) This includes
Qualitative - 10 potential
participants were selected
from the four health
communities in South
Yorkshire. (p.46 para 8)
Quantitative - All 199
dental practices in South
Yorkshire (p.46 para 11)
How sample was
recruited:
Qualitative - Purposive
sampling of principal
dentists ensured a full range
of perspectives was
included in the study. Time
since qualification and the
NHS/private mix of a
practice 10,11 both
influence perspectives of
involvement in general
health promotion in
quantitative studies. Other
factors such as dentists’ sex
and practice size were also
assumed to be influential
variables. (p.46 para 8)
Quantitative - A selfadministered questionnaire
was sent to a principal
Qualitative:
Content analysis was used to identify
codes and categorise the primary
pattern in the data. This analysis was
informed by the aims of the study and
as such asked three broad questions.
Firstly, it asked what the data suggest
about the range of dentists’ views of
general health promotion through public
health interventions. Secondly, what
they suggest about the range of
dentists’ views of the dental team’s
involvement in this activity; and lastly
whether any variation in views can be
adequately conceptualised. The data
were analysed by reading each
transcript and coding areas of interest
on index cards.33,34 From these
codes, categories were formed and
added to as each transcript was
analysed. A detailed descriptive
account of emergent theory was then
produced which was independently
checked by another researcher (PGR).
The data are presented below within
major themes that emerged from the
analysis with quotations to illustrate the
findings and allow the reader to judge
interpretation. (p.46 para 10)
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
dentists’ views on:
 General health promotion
through preventive health
interventions; and
 Dental teams’ involvement
in this work.
And by describing dentists’:
 Level of involvement in 7
different public health
interventions;
 Views of the relevance of
these interventions to their
work;
 Views of dentists’ and
PCDs’ involvement in
these interventions,
including any perceived
barriers to such
activity.(p.49 para.5)
Theoretical approach
[grounded theory, IPA etc]:
Qualitative:
State how data were
collected: Interviews were
audiotaped and transcribed as
fully as possible. A synopsis of
each interview, together with a
full transcript, was sent to the
relevant participant who was
invited to make comments if
they were at odds with their
intended meaning. No
modifications
Population and Sample
Selection
dentist at all 199 dental
practices in South
Yorkshire. The
questionnaire was then
piloted in 2 stages but
required minimal
modification. One principal
was selected from each
practice using random
number tables. (p.46 paras
11-12)
Qualitative:
How many participants
recruited: NR
Sample characteristics:
Age: NR
Sex: NR
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: NR
Occupation: Dentists
Education: NR
Socioeconomic position:
NR
Social capital: NR
Quantitative:
How many participants
recruited: 84.9% of 199
clinics receiving
questionnaires. 3 were not
Outcomes and Methods of Analysis
Notes by Review Team
to p.51 (para.1))
Key themes and findings relevant to
this review [with illustrative quotes if
available]
NOTE: Some of these findings are
more about whether dentists feel they
should make general health
interventions alongside oral health –
hence they aren’t relevant to this
particular study.
Limitations identified by
review team:
The paper does not specify
the response rate for the
qualitative study which is a
major weakness. In addition
there is ambiguity about the
responses from the second
and third mailings of the
quantitative survey as these
results aren't included.
Instead the authors simply
say they are comparable
without including any figures
for significance.
The qualitative data could be arranged
on a conceptual framework based on 2
core categories: Seeing health or
disease and The structure of dental
practice (this is shown in Fig 1 of the
paper) (p.47 para.1)
The paper does not
describe how the research
was presented and the
relationship between the
researcher and participants
is not discussed.
Seeing health or disease
While the qualitative sample
appears to be based on a
sound approach the context
of the different participants
in relation to this sampling
approach is not explained
and nor are any other
characteristics of the sample
provided.
NOTE: Paragraph numbering for the
results section is based on paragraphs
separated by blank space.
Qualitative results:
Dentists’ views could be arranged on a
spectrum according to the degree to
which their outlook was disease
(emphasising curative treatments) or
health-focussed (emphasising
prevention). Where the more diseasefocussed dentists did describe any
involvement, it tended to be centred on
the mouth. For instance, smoking
cessation advice might be given
The qualitative analysis
procedure is made explicit
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Study Details
Research Parameters
were requested.
What method(s):
By whom: NR
What setting: NR
When: NR
Quantitative:
State how data were
collected: A letter of
notification was sent to all
recipients 2 weeks before
distribution of the
questionnaire informing them
of the study. Questionnaires
were mailed with a covering
letter and postage-paid
envelope and were coded so
that non-responders could be
re-mailed. Areas of enquiry
included: practice details;
views of the relevance of
health interventions to their
practice; levels of, and barriers
to, involvement in health
interventions for both dentists
and PCDs (professionals
complementary to dentistry);
whether respondents would be
happy for suitably trained
PCDs to deliver health
interventions in their practice.
The health
interventions inquired on were:
prevention of smoking/tobacco
use; smoking cessation;
advice on alcohol
Population and Sample
Selection
completed adequately
leaving 83.4% useable for
analysis. (p.48 para.14)
Sample characteristics:
Age: NR
Sex: Male=87.9% (p.48
para.14)
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: NR
Occupation: Dentists
Education: NR
Socioeconomic position:
NR
Social capital: NR
Inclusion criteria: NR
Exclusion criteria: NR
Outcomes and Methods of Analysis
Notes by Review Team
because of staining on patients’ teeth
or mucosal changes rather than for
broader health promoting reasons.
(p.47 paras 2-4)
however the same cannot
be said for the quantitative
element. P values are
quoted based on
significance tests but it is
not stated what tests were
used (presumably chisquare). Surprisingly, given
the sample was quite large
and a result of randomised
design, the paper does not
include any tests of whether
the views of "health"
oriented and "disease"
oriented dentists differed.
This was probably because
the division between these 2
types of dentists was only
made in the qualitative
element of the study.
However such an exercise
in the quantitative element
could have really enhanced
the value of the paper and
provided and important
reinforcement to the
qualitative findings.
The structure of dental practice
Perceptions of the role of the dental
practice: Often the health-focussed
dentists felt that dental practices’ role
could include health interventions.
Views of the relevance of particular
public health interventions to dental
practice varied considerably. Generally
participants felt smoking cessation was
relevant to dental practice, whereas
there were diverse views on blood
pressure monitoring.(p.47 paras 6-8)
PCDs and dental practice: There was
broad agreement that a team approach
will become more important in dental
practice, especially if health
interventions are to be undertaken, but
participants recognised that not
all dentists held this view:
‘There is a fair proportion of dentists
who think that dentists do dentistry and
that’s it.’ (John, 28.11.02) (p.47
para.11)
Commitment and involvement: All
participants were already involved in
health interventions. However
involvement beyond smoking cessation
and dietary advice varied considerably.
Many health-focussed participants
Generally the findings are
clear and internally
consistent. However more
information on the
qualitative sample would
have made them more
convincing.
Some of the paper is
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
consumption; advice on diet
and calorie intake; advice on
prevention of skin cancer;
advice on physical exercise;
blood pressure monitoring.
(p.46 paras 12-13)
What method(s): Cross
sectional postal survey.
By whom: Sent by
researchers but self
completed.
What setting: Sent to dental
practices
When: Mailing of quantitative
survey was in 3 stages,
between April 2003 and July
2003
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
would have liked to undertake more
oral disease prevention. Others, with a
more disease focus, expressed
reticence and tended to get little
enjoyment from preventive dentistry:
focussed on non-oral health
interventions.
“There is not much pleasure to be
gained out of oral hygiene instruction in
my experience … I just don’t think I
would enjoy it [health interventions]
really.”’ (Kevin, 17.02.03) (p.47
para.14)
Views on commitment and involvement
of PCDs varied.
The study was approved by
an ethics committee but
other than that there is no
information on ethical
issues.
Evidence gaps and/or
recommendations for
future research: NR
Source of funding: NR
Participants were keen to delegate
preventive work to PCDs whether
related to oral or general health.
However, some had more negative
views of the role of PCDs and health
interventions, typified by this
medicalised view of prevention:
“If it requires medical background
knowledge then the hygienists
shouldn’t be doing it anyway.”
(Laurence, 18.12.02) (p.47 (para.17) to
p.48 (para.1))
Competence: Most participants did not
feel adequately trained to undertake
health interventions. They particularly
expressed a lack of confidence in their
communication skills. (p.48 para.3)
Advice on alcohol consumption was
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
perceived to be difficult, especially by
those with a disease focus:
“They might think it was prying and not
actually something that is anything to
do with their mouth and teeth – which is
what they expect a dentist to be asking
about.” (Kevin, 17.02.03) (p.48 para.4)
Effectiveness: No participant raised
the issue of effectiveness of health
interventions until the researcher
introduced it. Of note was that all of the
discussion was anecdotal rather than
evidence-based. Most perceived PCDs
to be effective. (p.48 para.7)
Resources: The fee-per-item payment
system discouraged dentists
undertaking work for which they could
not claim a fee, whether they were
health or disease-orientated. Many felt
that dentists’ involvement in health
interventions would be a poor use of
their time but many would have been
happy for PCDs to be involved as ‘lossleaders’. However, many felt that PCDs
had more time for prevention. (p.48
paras.10-12)
Quantitative results:
Principal dentists’ views on the
relevance of the 7 health
interventions
Proportion of dentists (base=164) who
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
thought that public health interventions
had at least some relevance to their
practice:
 Smoking prevention: 93.9%
 Smoking cessation: 92.1%
 Alcohol consumption advice:
79.9%
 Dietary advice: 88.4% (p.48
para.15)
NOTE: There are 7 interventions in total
but 3 are not related to oral health so
are not included.
Frequency of involvement in health
interventions
Most patients reported undertaking
health interventions at least
occasionally.(p.49 para.1)
Results for those who never undertook
interventions (base= 164):
 Smoking prevention: 14.6%
 Smoking cessation: 13.4%
 Alcohol consumption advice:
39.6%
 Dietary advice: 19.0% (p.48
Table 1)
Views of principal dentists of the
main barriers to dentists

The most frequently reported
barriers to dentists and PCDs were
‘insufficient funding’ and ‘poor use
of time’.
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis


Notes by Review Team
Significantly fewer dentists (p<0.05)
perceived ‘poor use of time’ and
‘lack of training/knowledge’ and
‘unlikely to be effective’ as barriers
for PCDs than they did for dentists.
‘Unlikely to be effective’ and ‘likely
to alienate patients’ were reported
most frequently for both dentists
and PCDs for advice on alcohol
consumption. (p.49 para.2)
PCDs undertaking health
interventions in dental practice
If these barriers were addressed, the
proportion of dentists (n = 166) who
agreed that appropriately trained
PCDs could undertake health
interventions were as follows:
 Smoking prevention: 74.2%
 Smoking cessation: 74.8%
 Alcohol consumption advice:
64.5%
 Dietary advice: 74.7% (p.48
para.3)
Responses to second and third
mailings of the questionnaire
A separate analysis of data from the
second and third mailings revealed that
dentists’ and practices’ characteristics
were similar to those of the first. The
attitudinal data were also comparable.
(p.49 para.4)
Conclusions: Dentists with a health
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
focus appeared more likely to support a
preventive approach and to have a
broader view of the role of the dental
practice. They supported the use of
PCDs, often citing the benefits of skill
mix. They also perceived that they
would be keen and able, having
received necessary training, to extend
their role to undertake health
interventions. In contrast, diseasefocussed dentists tended toward a
traditional, specific remit of the dental
practice with less enthusiasm toward
prevention. They had a positive view of
PCDs but this often emphasised
efficient treatment delivery. (p.49
para.6)
Apart from advice on physical exercise
and blood pressure monitoring, the
qualitative and quantitative parts of this
studyindicate that the health
interventions are considered to be
broadly relevant to dental practice.
However, levels of involvement in all
health interventions were lower than
might be expected given these views
(Table 1). These findings are
compatible with existing data on
smoking cessation, alcohol counselling
and blood pressure monitoring. (p.50
para.2)
As well as a dentists’ health-disease
orientation, other barriers to dental
involvement in this work related to The
structure of dental practice. Barriers
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
identified largely reflected the
inflexibility of the current GDS and
informed the content of the
questionnaire. (p.50 para.4)
The most commonly reported barriers
were ‘insufficient funding’ and ‘poor use
of time’. This concurs with previous
research on smoking cessation. Given
the fee-per-item payment system, the
high treatment need in the area and
workforce shortage this is unsurprising.
Any initiative to increase involvement in
interventions may fail unless workforce
shortages are addressed. (p.50 para.5)
It is surprising that ‘lack of
training/knowledge’ and ‘unlikely to be
effective’ were not cited more often as
barriers to involvement, given the lack
of evidence of effectiveness and the
limited training of most dentists in this
work. Although participants in the
qualitative study frequently cited a lack
of training as a barrier to involvement,
they rarely referred to effectiveness
without being prompted, and when they
did the evidence was largely anecdotal.
In part this may reflect a lack of
familiarity with the concept of evidencebased dentistry, as has been reported
previously. (p.50 para.6)
Given the workload of dentists and
chronic disease prevalence in the UK,
the use of PCDs to deliver health
interventions seems sensible. However
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
it is unclear whether the recent
expansion of PCD training could meet
this demand. Also it is essential that
PCDs’ remuneration encourages them
to remain within the NHS — in some
areas 80% of dental hygienists work
exclusively privately. Local
commissioning could provide
opportunities to recruit more PCDs and
remunerate them appropriately. (p.50
para.11)
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Study details
Population and setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author:
Fjellstrom M;
Yakob M; Soder
B
Source Population(s):
Sweden
Method of allocation: Participants
were divided into 2 groups by
drawing of lots, the control group
and the CBT group. This study was
an examiner blinded.
Oral health (clinical)
results:
Year: 2010
Sample characteristics:
Age: 20-30 years old
Sex: Female
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: NR
Occupation: NR
Education:
Physiotherepeutic
students
Socioeconomic
position: NR
Social capital: NR
Outcomes (include
details of all relevant
outcome measures
and whether
measures are
objective or
subjective or
otherwise validated):
Limitations
identified by
author:
Time is however a
factor to consider, it
takes more time
using CBT compared
with giving
information in a
traditional way.
Therefore, the time
limit has been a
problem, because
longer time with the
patient is necessary
when using CBT. [p
181, para.2 – p 182,
para.1]
Citation:
Fjellstrom M;
Yakob M; Soder
B (2010) A
modified
cognitive
behavioural
model as a
method to
improve
adherence to oral
hygiene
instructions--a
pilot study.
International
Journal of Dental
Hygiene 8, 178182
Country of
study: Sweden
Aim of Study:
The hypothesis
was that the use
of CBT leads to
better adherence
to oral hygiene
Setting: Not clear
Eligible population: All
healthy, and all had
teeth, but the third
molars were excluded [p
189, para.6]
State if eligible
population is
considered by the
study authors as
representative of the
source population: NR
Inclusion Criteria:
Report how confounding factors
were minimised: [quality
assessment]
Programme/Intervention
description:
What was delivered: At the first
visit, all the participants answered
the self-reporting questionnaire. Oral
clinical examinations were
performed, and the parameters
included were: Plaque index (PI) by
recording the presence of plaque on
mesial, distal, buccal and lingual
surfaces after painting Diaplac on all
exposed tooth surfaces (16), and the
red colour was also for a pedagogic
purpose. Gingival-index (GI) (17)
and gingival bleeding index (GBI)
(18) was recorded. Toothbrush (19)
and dental floss instructions on both
model and in the patient’s mouth
were given, and the patient
practiced the techniques during the
visit. The information to the
participants consisted of traditional
education and by showing pictures
of periodontal health and disease.
Outcome name:
Gingival Index
Outcome measure
validated: NR
Unit of
measurement: Level
(lower is better)
Time points
measured: After 3
weeks
Outcome name:
Plaque Index
Outcome measure
validated: NR
Unit of
measurement:
Percentage
Time points
measured: After 3
weeks
Outcome name:
Gingival Bleeding
Index
Outcome measure
Gingival Index
(Mean value)
Baseline Control
Group: 1
Post Intervention
Control Group: 1
Baseline CBT Group:
2
Post Intervention: 0
No p-values
provided
Plaque Index
(Percentage)
Baseline Control
Group: 55.5
Post Intervention
Control Group: 44.5
Baseline CBT Group:
77.5
Post Intervention: 8.5
No p-values
provided
Gingival Bleeding
Index (Percentage)
Baseline Control
Group: 23.5
Post Intervention
A compilation of
studies made so far
on the subject of
psychological
interventions for
change in behaviour
in view of
odontological
prophylaxis resulted
in the increase of
oral hygiene in the
test people. But the
studies did not show
any greater effect on
pocket-depth. The
quality on the
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and setting
Method of allocation to
intervention/control
habits compared
with traditional
instructions. The
purpose of this
project was to
create a modified
CBT model to
determine the
impact on
increased
adherence to oral
hygiene
instructions. And
in a pilot study
test, this model
was compared
with traditional
instructions. [p
179, para.4]
Healthy and had teeth [p
179, para.6]
The CBT group was further taught to
process the given information by
keeping a diary about thoughts and
feelings that develop during or prior
to tooth brushing and flossing during
2 weeks. They were asked to
visualise the toothbrush and dental
floss against the tooth while using
the tool and to reward themselves
after cleaning by letting the tongue
feel the smooth surface of the clean
teeth.
Study Design:
Controlled pilot
study
Quality Score
(++, +, or -): ++
External
Validity(++, +, or
-): - (not based
on an average of
scores) this study
is not meant to
have external
validity as a pilot
study of 4
Exclusion Criteria: NR
% of selected
individuals agreed to
participate: NR
Potential sources of
bias: NR
All participants received a
toothbrush, a roll of floss and
professional tooth cleaning at the
first visit for the same basic
conditions. After 3 weeks, the
participants returned for oral clinical
re-examination. They all answered
the same self-reported
questionnaire, and PI, GI and GBI
was registered again. The CBT
group brought their diaries for
evaluation. The 4 participants
cooperated of their own free will and
were informed that they could
interrupt their participation at any
time. [p 179, para.6]
Theoretical basis: CBT
How often: The pilot study included
2 visits with 3 weeks of interval.
Control/Comparator description:
What was delivered: At the first
visit, all the participants answered
Outcome definitions
and method of
analysis
validated: NR
Unit of
measurement:
Percentage
Time points
measured: After 3
weeks
Results
Notes by review
team
Control Group: 17
Baseline CBT Group:
24.5
Post Intervention: 0
Behavioural
Behavioural results:
Outcome name:
Self-reported
questionnaire
Outcome measure
validated: NR
Unit of
measurement:
Various open/closed
questions
Time points
measured: After 3
weeks
Self-reported
Questionnaire
The results of the
self-reported
questionnaire at the
first visit showed
varied knowledge
about gingivitis and
oral hygiene habits in
both groups. The
participants had
different dental floss
habits. 3 of the
participants
answered that their
gingiva bleeds when
cleaning their teeth.
One of the
participants
answered that she
had good oral health,
and 3 answered that
their oral health could
be better (Tables 1
and
2).
studies was low, and
there is a need to
increase the
demands on the
methods used in
studies in the future.
Psychological
treatments are
complex as it is
difficult to blind
patients and
therapist to
treatment condition
and in this study the
examiner was not
blinded. [p 182,
para.1]
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any
baseline differences
in important
confounders): NR
No p-values
provided
Limitations
identified by review
team:
Did not report any
details on source
population, or
describe recruitment
process.
Details on allocation
were not provided
with regards to
concealment, only
that participants
were divided into the
2 groups by drawing
of lots.
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Study details
participants
Population and setting
Method of allocation to
intervention/control
the self-reporting questionnaire. Oral
clinical examinations were
performed, and the parameters
included were: Plaque index (PI) by
recording the presence of plaque on
mesial, distal, buccal and lingual
surfaces after painting Diaplac on all
exposed tooth surfaces (16), and the
red colour was also for a pedagogic
purpose. Gingival-index (GI) (17)
and gingival bleeding index (GBI)
(18) was recorded. Toothbrush (19)
and dental floss instructions on both
model and in the patient’s mouth
were given, and the patient
practised the techniques during the
visit. The information to the
participants consisted of traditional
education and by showing pictures
of periodontal health and disease.
All participants received a
toothbrush, a roll of floss and
professional tooth cleaning at the
first visit for the same basic
conditions. After 3 weeks, the
participants returned for oral clinical
re-examination. They all answered
the same self-reported
questionnaire, and PI, GI and GBI
was registered again. The 4
participants cooperated of their own
free will and were informed that they
could interrupt the participation at
any time. [p 179, para.6]
How often: The pilot study included
Outcome definitions
and method of
analysis
Results
The self-reported
questionnaire for the
control groups
showed no difference
between the 2 visits,
and oral care habits
were unchanged
(Table 3). However,
in the CBT group, the
questionnaire
showed increased
knowledge about
gingivitis and the oral
health care changed
between the 2 visits.
They reported that
their oral health
increased, and they
had no more
bleeding from the
gingiva, and dental
flossing had become
a daily routine for
them (Table 4). At
the examination visit,
the participants in the
CBT group also
answered a
questionnaire about
the CBT diary (Table
5). The answers in
CBT group showed
different strategies in
how they used the
diary for support.
Notes by review
team
No p-values were
provided for main
effects or
differences, so
whether the stated
differences were
significant or not is
unclear.
3 weeks is a
particularly short
time period to see
significant
differences in clinical
outcomes, as the
authors state, further
investigation is
needed with a full
RCT.
Also, the study does
not state who
delivered the
intervention. CBT
may have been
delivered by a
specialist - it might
not be something
that a dentist would
be able to deliver
without training.
There was no
reference to the
validity of the selfreported
questionnaire; using
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Study details
Population and setting
Method of allocation to
intervention/control
2 visits with 3 weeks of interval.
Sample size at baseline:
Total sample N = 4
Intervention group N = 2
Control Group N = 2
Baseline comparisons: NR [this
was a pilot study with only 4
participants]
Study sufficiently powered (power
calculations and provide details): NR
[this was a pilot study with only 4
participants]
Outcome definitions
and method of
analysis
Results
Notes by review
team
Keeping the diary
had helped them in
increasing their
motivation and
awareness about oral
habits and gingivitis
and recommends the
method as a tool in
changing behaviour
for better oral health.
Comments to the
questions about the
diary among others
were: “‘It was hard to
do because I had to
think about what I
was feeling and why,
when I brushed my
teeth”. “I thought it
was easy because I
only used the diary
as a support the days
it was hard to
motivate myself to
brush and floss”. [p
180, paras 2 and 3 –
please refer to tables
for further details if
necessary]
a validated measure
could provide more
robust results.
Evidence gaps:
This pilot study can
present material for
discussion where
future studies in this
rarely unknown field
are needed.
Furthermore, as a
suggestion,
randomised clinical
trials are needed for
evidence in the
effectiveness of CBT
on oral health
improvements.
Source of funding:
NR
No p-values
provided
Attrition details:
Indicate the number
lost to follow up and
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Study details
Population and setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control): NR [This
was pilot study of 4
participants]
Conclusion: This
pilot study shows that
using a modified
model of CBT, by
keeping a diary,
resulted in increased
adherence to oral
hygiene and
knowledge about
gingivitis, compared
with traditional
instructions.
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: Grant, E.
et al
Study design: A
phenomenological research
design was selected to
investigate positive oral
health outcomes because it
enabled the generation of
detailed data about
participant experiences. 10
semi-structured interviews
conducted with key players
supporting the oral health of
4 people with disabilities.
Population the sample
was recruited from: The
study focussed on
positive oral health
outcomes achieved with 4
people with intellectual
disability who required 24
hour support from a
disability care service. At
the time of the
intervention, these
individuals were living in a
supported, communitybased accommodation in
an urban setting in
Queensland, Australia.
The subjects had limited
verbal communication
abilities and were unable
to provide informed
consent, therefore key
players were interviews –
including dental
professionals, directsupport workers, and
other professionals who
worked with people who
had disabilities (p.71,
pa.11)
Brief description of method and process
of analysis [including analytic and data
collection technique]:
Limitations identified by
author:
Year: 2004
Citation: Grant,
E., G. Carlson,
and M. CullenErickson, Oral
health for people
with intellectual
disability and
high support
needs: Positive
outcomes.
Special Care in
Dentistry, 2004.
24(2): p.70-79.
Country of
study: Australia
Quality Score
(++, +, or -): +
Research aims, objectives,
and questions:
The study explored and
documented 4 situations in
which positive oral health
outcomes occurred for
people with mental
retardation and moderate to
high support needs.
Theoretical approach
[grounded theory, IPA
etc]: Based on
phenomenological
approaches
State how data were
collected:
What method(s): Semi
structured interviews. One
researcher (author EG)
collected data from the
participants using semi
How sample was
recruited:
Situations involving a
positive oral health
outcome for a person with
intellectual disability were
Following each interview, tapes, and field
notes were transcribed verbatim. Inductive
thematic analysis was used to organise the
transcribed information from three
interviews into categories and
subcategories based on experiences at the
dental office and experiences at home. A
coding tree was developed and used to
code the remaining transcripts. This
process was facilitated by the computer
program Nvivo. Data coded at each
thematic category was then synthesised
and summarised.
Rigor: coding checks were undertaken (by
second and third researcher); participants
provided with transcript and summary of
results to check.
Key themes and findings relevant to this
review [with illustrative quotes if
available]
Perceptions of positive outcomes:
The support worker participants and dental
professionals had different perceptions of
what constitutes a positive oral health
outcome: dentists = high standard of oral
health; support worker = acceptance of
intervention by person with disability.
Depends on the person’s relationship with
The present study relied on
participants recalling
situations that occurred both
recently and a number of
years previously. This has the
potential for participants to
recall information inaccurately.
However, by exploring the
experiences and perspectives
of more than one of the key
players involved in the oral
health intervention, individual
accounts could be compared
and confirmed.
Small numbers of situations
described limits our ability to
generalise these findings to
other settings. (However,
the in-depth nature of this
qualitative research would
enable direct support workers,
disability professionals, and
dental professionals to identify
similarities between the
experiences of the people with
intellectual disability in the
present study and individuals
whom they support.)
Limitations identified by
review team:
117
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
structured interviews. An
interview guide and
questions were developed,
based on the literature
review, and the researchers’
experiences and reflections
on the research objectives
and questions. This enabled
the interviewer to focus on
specific issues related to the
topic while still retaining
flexibility within the
interview.’
The length of the interviews
varied, max length was 1
hour.
Interviews were recorded
onto an audio-tape, with the
participant’s consent. One
participant requested a
telephone interview, and the
researcher documented this
participant’s responses by
making extensive written
notes.
By whom: One researcher
(author of paper)
What setting: NR
When: NR
Population and Sample
Selection
identified by 2 methods,
convenience and
snowball sampling.
Through her work in the
disability service, one
researcher (author MC-E)
was able to identify 4
situations in which
positive oral health
outcomes had occurred.
In addition, participants
involved in the initial
interviews for each
situation were asked if
they were able to identify
other individuals involved
in the successful oral
health intervention (p.71,
para.11).
Following informal
discussion between the
third researcher (author
MCE), unit managers, and
direct support workers at
the disability service, the
first researcher (author
EG) was provided with the
names and contact details
of an initial contact person
for each situation
involving positive
outcomes. Potential
participants were
contacted by telephone.
They were provided with
an explanation of the
Outcomes and Methods of Analysis
Notes by Review Team
the individual.
Key themes:
General strategies:
- Giving it a go: identified as a
strategy when using dentures.
- Maintaining consistency: when
demonstrating techniques
“Probably the main success was
due to the fact that the person had
very consistent staff whom she
trusted”.
- Facilitating positive experiences:
e.g. receiving feedback, getting
positive comments; linking the visit
to the dentist wit positive
experience (e.g. going to the coffee
shop after the dentist)
- Taking as much time as needed:
some felt that allowing time was
necessary for a positive outcome
“proceeding very slowly”
- Respecting and encouraging
choice: “ whenever xxx wasn’t keen
on going (to the dentist) we didn’t
go”
Oral health strategies used at the dentist:
- Timeliness and frequency of dental
appointments: participants found it
was helpful to schedule
appointments at regular intervals
and more frequent appointments
when fittings/treatment taking
place.
- Communication between dental
professionals, direct support
Although paper highlights that
the research is explained
clearly to participants – role of
the researcher is not outlined
in paper.
Setting of interviews not
clearly described.
Evidence gaps and/or
recommendations for future
research:
Further investigation of
strategies
and environmental influences
on oral health for people with
intellectual disability is
warranted. In particular,
qualitative research into
communication with the
person with intellectual
disability during oral health
intervention and qualitative
research about oral health
experiences involving
interviews with people with
intellectual disability who are
able to communicate should
occur.
Source of funding: NR
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Study Details
Research Parameters
Population and Sample
Selection
nature of the study as well
as the purpose and format
of the research.
Following this notification,
their willingnessto
participate in the study
was ascertained.
Participants were sent the
interview questions prior
to the interview to allow
consideration of their
responses (p.72, para.4).
How many participants
recruited: 10 key players
(support worker, dental
professional or other
professionals) who
worked with the 4 people
with intellectual disability
were interviewed (p.71,
para.11).
Sample characteristics:
(of the 10 key players who
were interviewed):
Age: NR
Sex: NR
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Australia
Occupation: dental
professionals, direct
support workers, and
Outcomes and Methods of Analysis
Notes by Review Team
workers, and people with
disabilities: dentists explaining tooth
brushing etc to support workers
was perceived beneficial, and an
awareness amongst support
workers of the oral health problems
of the individual was beneficial.
Support worked advocated on
behalf of individuals.
Communication contributed to the
success of oral health intervention
for all of the people with intellectual
disability.
- The dental environment: smaller,
more intimate dental environment
preferable. Relationship with the
dentist important: “really
accommodating, considerate and
respectful”.
Oral health strategies used ta home:
- Problem solving: tailored
communication to solve problems
- Assisting the person with disability
to learn skills: “We decided that it
was best to go right back to the first
step and that is choosing your
toothbrush, learning how to use it
and the step-by-step process”
- Desensitisation: a way of gradually
familiarising the person with
disability with oral health
procedures. To decrease fear and
anxiety.
- The home environment:
consideration of the physical
environment, positive feedback
from the community, and a support
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Study Details
Research Parameters
Population and Sample
Selection
other professionals
(psychologist and unit
managers) who cared for
their 4 people with
disabilities
Education: NR
Socioeconomic
position: NR
Social capital: NR
Outcomes and Methods of Analysis
Sample characteristics:
(the 4 people with
intellectual disabilities):
Age: 2 in their 30s and 2
in their 50s
Sex: NR
Sexual orientation: NR
Disability: intellectual
disability
Ethnicity: NR
Religion: NR
Place of residence:
Supported
accommodation in urban
Queensland, Australia
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
This study explored positive oral health
outcomes achieved with 4 people with
intellectual disability and identified
strategies, perceptions, and environmental
factors that may have contributed to the
success. Many of these strategies, such as
those related to choice making,
communication, taking as much time as
needed, and teaching skills are consistent
with general literature in the field of
intellectual disability. However, there has
been little research conducted in relation to
their specific application to oral health.
Inclusion criteria: NR
Exclusion criteria: NR
Notes by Review Team
from family members and the
disability service were
environmental factors identified as
contributing to the positive oral
health outcomes achieved with the
people who had intellectual
disability.
Conclusions:
It is important for people who work with
populations that have disabilities to
recognise that existing general teaching
and learning strategies are relevant for use
in oral health. It is also important for
disability services to promote the
knowledge of specific oral health strategies
and environmental influences among direct
support workers.
/Dentists also could implement the
strategies and environmental
considerations in their own practices and
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
may also be in the position to promote the
implementation of strategies by direct
support workers in the provision of oral
health care in the person’s home. Disability
professionals such as psychologists,
occupational therapists, and speech and
language pathologists also may assist
direct support workers and dentists in
implementing the strategies and
environmental changes identified in this
study.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
Author: R.V.
Harris, Y.M.
Dailey and R.S.
Ireland
Source
Population(s):
General Dental
Practitioners (GDPs)
who were listed as
providing NHS
treatment by the
appropriate Health
Authority and who
worked in Liverpool
(n=202); the Wirral
(103); and St Helens
and Knowsley (114)
(p.530 para 5)
Method of allocation (describe
how selected individuals/clusters
were allocated to intervention or
control groups – state if not
reported): N/A. – not a controlled
study
Study is not an
intervention so
there are no
outcomes as such
Advice regarding the
fluoride concentration of
toothpaste to be used.
Limitations
identified by author:
It could be argued
that this methodology
is less than ideal as a
means to gather data
on reported activity
since the practitioner
can simply state what
he feels to be the
accepted practice,
rather than reporting
what actually takes
place. However
Saunders et al.
argued that GDPs
were being honest,
since only a quarter
said that they used a
rubber dam routinely,
even though its use
would have been
advocated to all of
these practitioners at
undergraduate level.
(p.532 para 6)
Year: 2002
Citation: Harris,
R.V., Y.M.
Dailey, and R.S.
Ireland, General
dental
practitioner
advice regarding
the use of
fluoride
toothpaste in 2
areas with a
school-based
milk fluoridation
programme and
one without such
a programme.
British Dental
Journal, 2002.
193(9): p. 52933; discussion
519.
Country of
study: England
Aim of Study:
To describe the
Through return of
uncompleted
questionnaires and
telephone contact with
the dental practices
concerned, it
transpired that only
329 general dental
practitioners on the
original lists were still
actively engaged in
NHS general dental
practice in the area
(167 GDPs in
Liverpool, 77 in the
Wirral and 85 in St
Helens). (p.530 para 8)
Setting: Survey of
Report how confounding factors
were minimised: The possibility of
contamination - which may have
occurred if a GDP in one area
spoke to a colleague in another
area and change their responses
to the questionnaire accordingly does not appear to have been
considered.
The potential for GDPs to say they
do what is accepted practice even
when they don't is recognised by
the authors but no adjustments
were made for this challenge to the
paper's validity.
Data Collection Description:
What was delivered: A focus
group of 4 GDPs was set up to
discuss the research area and
questionnaire design.
Questionnaires were coded
according to the name of each
GDP on the list so that nonresponse could be followed-up.
Second and third mailings were
Method of
analysis (indicate if
ITT or completer
analysis was used
and if adjustments
were made for any
baseline
differences in
important
confounders): In
order to assess the
validity and
reliability of the
questionnaire, a
shortened version
containing key
questions was sent
to a sample of 50
GDPs who had
responded, and
their response to
the first and second
issues of the
questionnaire were
compared. The
data were analysed
using SPSS
computer software.
Chi-Squared tests
Proportion giving advice:
 42% reported that they
gave advice on the
fluoride concentration
of toothpaste to be
used by child patients
 A further 54% said that
they have this advice
along with other
members of the dental
team
 3% said that no-one in
the practice gave
advice on the fluoride
concentration of
toothpaste
 2% reported that this
was done by the
hygienist, dental nurse
or receptionist
(p.530 para 10)
More information in Table
1
Content of advice:
 16% of GDPs do not
appear to specify the
concentration of
fluoride toothpaste
As well as
questionnaire validity,
questionnaire
reliability (how
consistent is the
information supplied
when the same
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Study details
Population and
setting
Method of allocation to
intervention/control
knowledge and
practice of
general dental
practitioners
(GDPs) working
in Liverpool
(where there is
no milk
fluoridation
programme) and
St Helens and
Knowsley, and
the Wirral (where
children have
fluoridated milk
in schools and
preschools)
relating to the
advice given for
child patients
regarding the
use of fluoridated
toothpaste,
tablets and
rinses (abstract/
p.530 para.4)
GDPs
carried out as well as telephone
calls to prompt non-responders.
(p.530 paras 5-6)
Theoretical basis: An important
part of preventive dental care for
families with young children is the
use of fluoride and fluoridated
toothpaste, tablets or rinses which
may play a role in the prevention of
caries. However there has been an
increasing awareness of the risk of
developing enamel opacities
through too high a fluoride intake
during tooth development. This has
to be balance against the obvious
benefits that occur in the reduction
of dental carries. (p.529 para.1)
By whom: GDPs
To whom: GDPs
How delivered: Postal
questionnaire
When/where: Questionnaires
issued between January 2001 and
July 2001 (p.530 para.6)
How often: Once
How long for: 7 month
questionnaire
Study Design:
Cross-sectional
survey of Dental
practitioners
Quality Score
(++, +, or -): -
Location (urban or
rural): Liverpool; St
Helens and Knowsley;
and the Wirral
(abstract) – urban
areas with partial
exception of the Wirral
Sample
characteristics:
Age:
Sex: Male=74% (173);
Female= 26% (61)
(p.530 para.9)
Sexual orientation:
Disability:
Ethnicity:
Religion:
Place of residence:
NR (for place of work
see totals for different
areas in next column)
Occupation: GDP
Education: Qualified
Dentists
Socioeconomic
position: N/A.
Social capital: NR
Demographic details
are representative with
respect to gender of
GDPs across the
Sample size:
Total sample N = 234 (response
rate= 71%)
Liverpool N = 102
The Wirral N = 78
St Helens and Knowsley N= 54
Outcome
definitions and
method of
analysis
and Kappa tests
were carried out
where appropriate.
(p.530 paras 7-8)
Results
36 GDPs returned
the shortened
questionnaire.
There was
substantial
agreement (Kappa=
0.78) for the
question “Are there
any schools in your
area where children
receive fluoride
milk?” and also
substantial
agreement (Kappa=
0.61) for the
question about the
questions GDPs
asked of children
and their parents
when giving
preventive advice.
There was fair
agreement
(Kappa=0.21) when
GDPs were asked
about the advice
they gave on the
amount of
toothpaste to use.
(p.532 para.4)



used – some of the
comments indicated a
lack of awareness of
different
concentrations
For caries free
children under 7 years
only 64%b (144) of
GDPs gave the correct
advice to use a low
fluoride toothpaste in
line with clinical
guidelines
Over a quarter of
GDPs (28%, 64) also
advised children of this
age with high caries to
use low fluoride
toothpaste.
The proportion of
GDPs giving the
accepted advice to be
used for caries-free
children under 7 years
of age was compared
between districts with
a milk fluoridisation
programme (63%, 79)
and the one without
(64%, 65) but no
association was found
2
(X =0.032, P>0.05)
(p.531 paras 1-2) See
Table 2 for additional
Notes by review
team
measurement is
performed more than
once) should be
considered. When
key points of the
questionnaire were
reissued to a subset
of GDPs to test
reliability, it was
found that some
practitioners who had
said that there were
no schools in their
area where children
received fluoride milk,
changed their reply to
‘yes’ when given the
questionnaire a
second time. It is
possible that the
issue of the first
questionnaire may
have prompted the
GDP to make some
enquiries about any
fluoridated milk
programme in the
area. (p.532 para.8)
Limitations
identified by review
team:
The eligible and
source populations
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Study details
Population and
setting
Method of allocation to
intervention/control
External
Validity(++, +,
or -): ++
country with 79% of
males on the GDC
register and 21%
females. (p.532 para.9)
(p.530 para.9)
Eligible population
(describe how
individuals, groups, or
clusters were recruited,
e.g. media
advertisement, class
list, area): All GDPs in
source population –
see above
State if eligible
population is
considered by the
study authors as
representative of the
source population:
N/A.
Inclusion Criteria: NR
Exclusion Criteria: 31
GDPs were listed as
working in more than
one area and 12 of the
listed GDPs were
working in practices
restricted to
orthodontics or oral
surgery; these were
excluded. (p.530
Eight GDPs (3%) never saw any
children and were therefore
excluded from any further analysis.
(p.530 para.9)
Baseline comparisons (report
any baseline differences between
groups in important confounders):
N/A. – not a longitudinal or
experimental study
Study sufficiently powered
(power calculations and provide
details):
Outcome
definitions and
method of
analysis
Results
data
For the questions
on ‘advice
regarding the
fluoride
concentration of
toothpaste to be
used’ and ‘advice
regarding the
amount of
toothpaste to be
used’ dentists were
given 6 scenarios
involving child
patients and were
asked whether they
would advise a low
fluoride toothpaste
(<600 ppm),
standard fluoride
toothpaste (1,000
ppm) or high
fluoride toothpaste
(about 1,500 ppm).
The 6 scenarios
were a) for caries
free children under
7 years, b) for high
caries children
under 7 years, c)
for caries-free
children with mixed
dentitions, d) for
high caries children
with mixed
Advice regarding the
amount of toothpaste to
be used





For children under 7
years of age 20 (9%)
of GDPs did not
specify the amount of
toothpaste which
should be used when
advising the patient
and their parent
56-75% described the
amount of toothpaste
they advised as peasized
5-8% described the
amount they advised
as a smear
9-21% advised that a
small amount should
be used.
When comparing the
amount advised to
children under 7 –
significant differences
were seen both for
children who were
2
carries free (X = 18.86
p<0.01) and for those
with high caries
2
(X =11.23, p<0.05)
Notes by review
team
are almost the same.
A few GDPs were
excluded due to
location, specialism
or (in terms of
responses) because
they did not work with
children but this is not
many. There is some
ambiguity over
whether the study
authors are claiming
the study is
representative of the
whole UK. The study
authors note that the
gender composition
of interviewees
reflects that of the
country at large but
this is either
unnecessary to point
out (as the study is
just representative of
the areas covered) or
inadequate (as the
study would need to
be undertaken in
other areas in some
form of cluster
sample for it to be
nationally
representative).
The response rate
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
para.5)
% of selected
individuals agreed to
participate: 71%
response rate
Potential sources of
bias:
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
dentitions, e) for
caries-free children
with a full
permanent dentition
and f) for high
caries children with
a full permanent
dentition (p.530
para.11).
Results
Notes by review
team

was 71% so it is likely
the selected
participants are
representative.
However no
information is given
on whether there
were any differences
between nonrespondents and
respondents.
Fewer GDPs specified
a pea-sized amount
for older children and
more did not specify
an amount
Other advice related to
toothpaste usage
The majority of GDPs
reported advising that
toothbrushing should be
supervised, particularly for
children under 7 years of
age, either for those with
high caries (97%, 219
GDPs) or caries free
(85%, 193 GDPs), Table
4. Many GDPs (81%, 183)
still advised supervision for
those with high caries in
the mixed dentition. Over
half the GDPs advised
spitting out after brushing
for children under 7 years,
both for those who were
caries-free (59%, 133) and
for those who had high
caries (53%, 119). (p.531
para.4)
Knowledge of the milk
fluoridisation
programme
Reliability was tested
using Kappa
coefficients. Of the 3
questions mentioned
substantial
agreement was found
for 2 of them and fair
agreement for the
remaining question.
The study authors
note potential
limitations concerning
the study's validity as
GDPs might simply
state what he/she
feels is the accepted
practice rather than
what actually goes
on.
As mentioned, the
focus was not on
explanation as such.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team

However in some
cases - the amount of
toothpaste advised
(p.531 para.2) multiple explanatory
variables were
considered including
gender and years of
qualification
alongside presence
or absence of a milk
fluoridation
programme.



Of the 226 GDPs
responding who saw
child patients regularly
in their practice, 101
worked in Liverpool
where there is no
programme and 125
worked in either the
Wirral or St Helens
and Knowsley where
children receive
fluoride milk.
When asked if there
were any schools in
their area where
children receive
fluoridated milk, 78%
(97) of GDPs in the
Wirral and St Helens
replied there was, with
the remainder replying
either ‘No’ (2%, 3) or
‘Don’t know (20%, 25).
In Liverpool (where
there is no milk
fluoridation
programme) 91% (92)
said either that there
was no milk
fluoridation or that they
did not know.
Nine dentists in
Liverpool said that
there was a milk
The analytical
methods seem
appropriate given the
study was descriptive
in nature. While the
article acknowledges
that levels of
awareness by GDPs
of the milk fluoridation
programme may
affected their
responses it might
have been useful to
have some statistical
measures which
controlled for this.
Only p values were
given.
Evidence gaps:
Alternative ways of
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
fluoridation
programme in schools
in their area
(p. 531 (para.5) and
p.532 (para.1)
In terms of whether the
existence of the milk
fluoridisation scheme
featured in any discussion
on fluoride toothpaste:
 There was no
difference between the
proportions of GDPs in
areas with a milk
fluoridation
programme (59%) and
GDPs in Liverpool
(53% (χ2=1.03,
p>0.05)). (p.532
para.2)
 59% (74) of GDPs
working in the Wirral
or St Helens and
Knowsley claimed they
asked routinely asked
if the child had fluoride
milk at school
compared with 7% (7)
in Liverpool (χ2=66.37,
P<0.001). The 7
dentists in Liverpool
corresponded with
those dentists who
Notes by review
team
collecting activity data
such as checking
dental records and
payment schedules
can be used to try to
validate self-reported
activity. However,
these methods in
themselves give
insufficient detail in
relation to the
rationale behind the
practitioners’ choice
of treatment. In the
case of preventive
advice, validation
could only really be
achieved through
observing the GDP
at work. This perhaps
could be undertaken
as a further study.
(p.532 para.7)
Source of funding:
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results


Notes by review
team
mistakenly thought
schools in their area
gave out fluoride milk.
(p.532 para.2)
63% (79) of GDPs in
the Wirral and St
Helens and Knowsley
said that they advised
a low fluoride
toothpaste for caries
free children under the
age of 7, compared
with 64% (65) of GDPs
in Liverpool,
(χ2=0.032,P>0.05).
(p.532 para.3)
38% (48) of Wirral and
St Helens and
Knowsley GDPs said
that they advised a
standard fluoride
toothpaste for high
caries children under 7
years of age,
compared with 39%
(39) of Liverpool GDPs
who gave this advice
for high caries children
of this age (χ2=0.01,
P>0.05). (p.532
para.3)
Attrition details:
Indicate the number lost to
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
follow up and whether the
proportion lost to follow-up
differed by group (i.e.
intervention vs control)
N/A. (not a longitudinal
survey)
Conclusion:
There are clear clinical
guidelines regarding the
advice that should be
given concerning the use
of fluoride toothpaste by
young children. It appears
that although many GDPs
give advice that concurs
with the guidelines, there
are a significant number
who either do not discuss
the subject fully with the
parent concerned (for
example by not specifying
the concentration of paste
to be used), or give advice
which contradicts the
guidelines (for example by
advising caries free
children under 7 years of
age to use a medium or
high fluoride toothpaste).
For evidence-based
dentistry to become a
reality in this area, ways
must be found to
disseminate the available
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
guidelines more fully and
increase their acceptance
and use by practitioners.
(p.533 para.3)
130
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Hausen,
H., et al.
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): The children
attending this examination were
divided randomly into two
groups using computergenerated random numbers.
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
For each outcome
report
Limitations
identified by
author:
NR
Citation: Hausen,
H., et al.
Noninvasive control
of dental caries in
children with active
initial lesions. A
randomised clinical
trial. Caries
research, 2007. 41,
384-91
Source
Population(s):
All 5th and 6th graders
(11- and 12-year-olds)
in the town of Pori,
Finland, who started
the 2001–2002 school
year, except for
mentally disabled and
handicapped children
attending special
schools (n = 1,691).
Of the 1691, 577 were
eligible to participate
and randomised.
Country of study:
Finland
Setting: Public dental
clinics in Pori, Finland
Aim of Study: The
aim of this study
was to investigate
whether DMFS
increment can be
decreased among
children with active
initial caries by oral
hygiene and dietary
counselling and by
using non-invasive
clinical measures of
caries control.
Location (urban or
rural): Pori, Finland
(NR)
Year: 2007
Study Design:
Parallel RCT
Sample
characteristics:
Age: 11 and 12 year
olds. Mean age was
11.9 years
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Report how confounding
factors were minimised: NR
Programme/Intervention
description:
What was delivered:
Oral hygiene and dietary
counselling: for each child the
content of the intervention was
based on his/her individual
needs according to the clinical
findings, a questionnaire and
conversations during sessions.
The dental hygienist and the
child discussed ways of
reversing the active lesion and
preventing the onset of new
lesions. The child was
encouraged to take
responsibility for his/her own
dental health with the support of
dental personnel.
Children were given
Outcome name: DMFS
values
Outcome definition:
DMFS increments over
time
Outcome measure:
Exam
Outcome measure
validated: NR
Unit of measurement:
Mean DMFS
increments
Time points
measured: Difference
between start and
middle (2001-2003) and
start and end (20012005)
Outcome name:
Visible plaque
Outcome definition:
Index tooth surfaces
with visible plaque
Outcome measure:
Exam
Outcome measure
validated: NR
Total sample:
Baseline:
Follow up (all time
points)
End point:
Intervention group(s):
Baseline
Follow up (all time
points)
End point
Control group(s)
Baseline
Follow up (all time
points)
End point
Means, SDs, pvalues, CIs, Effect
sizes, SEs
Oral health (clinical)
results:
Limitations
identified by review
team:
The setting does not
reflect a usual UK
dental practice as it
is in Finland.
Power calculation not
reported
Evidence gaps:
Costs were not
considered in the
current study, but a
further challenge will
be to design a
regimen that is not
only efficacious but
also cost-effective.
Source of funding:
NR
Mean DMFS
increments
Mean (95% CI)
Intervention group:
Baseline to midpoint: 1.86 (1.50,
131
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
The children
attending this
examination were
divided randomly
into 2 groups using
computer-generated
random numbers.
Pori, Finland
Occupation: School
children
th
th
Education: 5 and 6
graders
Socioeconomic
position: NR
Social capital: NR
toothbrushes, fluoride
toothpaste and fluoride lozenges
throughout the study period.
Quality Score (++,
+, or -): +
External
Validity(++, +, or -):
+
Eligible population:
th
th
All 5 and 6 graders
in the town invited
(except for mentally
disabled and
handicapped children
attending special
schools).
93% of the children
attended the baseline
screening
appointment at which
they were screened
for the presence of
active initial caries
lesions. Children with
at least one active
lesion were given an
informed consent form
to be taken home for
their parents’
signature. Those for
whom consent was
obtained were invited
for a baseline dental
examination. 577 of
Active initial caries lesions were
cleaned professionally and
treatment was applied twice at
an interval of 1-2 weeks. This
was repeated until the lesion
seemed to be reversed.
Throughout the study period, the
dental hygienists (who gave the
counselling) were given caching
and support and their work was
monitored regularly.
Children in the experimental and
control groups were, along with
their peers in Pori, equally
exposed to community level
promotion of oral health that was
implemented during the course
of the randomised controlled
trial. This involved providing
correct information on oral
health problems and their
prevention, i.e. avoiding frequent
snacking, brushing twice a day
with fluoride toothpaste and
using xylitol after meals
(information included in the
counselling of the experimental
group)
Theoretical basis: N/A
By whom: Counselling = Dental
Outcome definitions
and method of
analysis
Unit of measurement:
%
Time points
measured: Baseline
(2001) and End (2005)
Outcome name:
Gingival bleeding
Outcome definition:
Gingival bleeding
scores
Outcome measure:
Exam
Outcome measure
validated: NR
Unit of measurement:
Scores 2-3 (Loe 1967)
Time points
measured: Baseline
(2001) and End (2005)
Other outcomes:
dietary habits and tooth
brushing frequency.
Use of xylitol lozenges
and chewing gum and
fluoride lozenges (Full
data not shown in
paper).
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
NR
Time points
Results
Notes by review
team
2.21), n = 242
Baseline to end point:
2.56 (2.07, 3.05) n =
250
Control group:
Baseline to midpoint: 2.44 (2.12, 2.77)
n = 251
Baseline to end point:
4.60 (3.99, 5.21) n =
247
Difference (between
intervention and
control group):
Baseline to midpoint: 0.59 (1.07, 0.11)
p value 0.0164
Baseline to end point:
2.04 (2.82, 1.26) p
value <0.0001
Visible Plaque
Mean (95% CI):
Intervention group(s):
Baseline: 7.6 (6.1, 9.1)
n = 250
End point: 6.7 (4.8,
8.6) n = 250
Control group(s)
Baseline: 7.6 (5.9, 9.3)
n = 247
End point: 7.4 (5.3,
132
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
the initial 1691 were
eligible and were
randomised.
hygienist. One experienced
health dentist examined the
children’s teeth. She had been
carefully trained for the
examination and did not
participate in the dental care of
the children.
State if eligible
population is
considered by the
study authors as
representative of the
source population:
Inclusion Criteria:
(as above)
Exclusion Criteria:
Mentally disabled and
handicapped children
attending special
schools
% of selected
individuals agreed to
participate:
93% (1691). Of those
577 were eligible.
Potential sources of
bias:
NR
To whom: Patients – children
aged 11-12
How delivered: Counselling,
instructions, cleaning, materials
(toothpaste, lozenges)
When/where: Public dental
clinics in Pori, Finland
How often: After 2 years and at
the end of the study the children
were examined using the same
methods as at the baseline
examination.
How long for: In both groups,
the average follow-up period
was 3.4 years (95% CI 3.42,
3.43 in both groups).
Control/Comparator
description:
What was delivered: Dentists
were responsible for all dental
care of the children in the control
group. Measures for caries
control were those given
normally in the public dental
clinics of Pori. In principle, this
included applications of fluoride
varnish and health education on
Outcome definitions
and method of
analysis
measured: Baseline
(2001) and end of
follow-up (2005)
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders):
ITT - NR
To compare the groupspecific cross-sectional
DMFS values, 3.4-year
DMFS increments and
percentages of index
tooth sites with visible
plaque and gingival
bleeding, mean values
and their
95% confidence
intervals were
calculated. The mean
difference in the DMFS
increment between
experimental and
control group and its
95% confidence
intervals were also
calculated. This
difference was also
expressed by means of
Results
Notes by review
team
9.4) n = 247
Start point p value
(intervention and
control): 0.9938
End point p value
(intervention and
control): 0.6457
Gingival bleeding
Mean (95% CI):
Intervention group(s):
Baseline: 13.5 (11.3,
15.7)
End point: 15.4 (12.8,
18.1) n = 250
Control group(s)
Baseline: 11.5 (9.5,
13.5)
End point: 19.1 (15.9,
22.2) n = 247
Start point p value
(intervention and
control): 0.1861
End point p value
(intervention and
control): 0.0824
Behavioural results:
Dietary habits and
tooth brushing
133
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
dietary and oral hygiene habits.
The study protocol included no
guidelines regarding the selfcare of children in the control
group.
Children in the experimental and
control groups were, along with
their peers in Pori, equally
exposed to community level
promotion of oral health that was
implemented during the course
of the randomised controlled
trial. This involved providing
correct information on oral
health problems and their
prevention, i.e. avoiding frequent
snacking, brushing twice a day
with fluoride toothpaste and
using xylitol after meals
By whom: Dentists were
responsible for the dental care
of all the children in the control
group.
One experienced health dentist
examined the children’s teeth.
She had been carefully trained
for the examination and did not
participate in the dental care of
the children.
To whom: Patients – children
aged 11-12
How delivered: Normal dental
care, oral health education
When/where: Public dental
Outcome definitions
and method of
analysis
the prevented fraction; t
tests for independent
samples were used to
evaluate the statistical
significance of
differences in the mean
values. The significance
of differences in oral
health habits was
evaluated by means of
chisquare tests.
Results
Notes by review
team
frequency. Use of
xylitol lozenges and
chewing gum and
fluoride lozenges (Full
data not shown in
paper).
Only reported results:
Based on the
questionnaires, at
baseline there were no
statistically significant
differences in dietary
habits or toothbrushing
frequency between the
experimental and
control groups. At the
end of the follow-up,
children in the
experimental group
reported using xylitol
lozenges and chewing
gum and fluoride
lozenges significantly
more frequently than
those in the control
group. Other
differences in dietary
habits were slight and
non significant, nor was
there a significant
difference in reported
toothbrushing
frequency between the
groups at the end of
the follow-up. (p.389
para.2)
134
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
clinics in Pori, Finland
How often: After 2 years and at
the end of the study the children
were examined using the same
methods as at the baseline
examination.
How long for: In both groups,
the average follow-up period
was 3.4 years (95% CI 3.42,
3.43 in both groups).
Outcome definitions
and method of
analysis
Results
Notes by review
team
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control)
After randomisation:
Sample size at baseline:
Total sample N = 577
Intervention group N = 278
Control Group N = 282
Baseline comparisons (report
any baseline differences
between groups in important
confounders): No difference in
mean age between the children
in the experimental and control
groups or between those who
completed the study and those
who were lost to follow-up.
There was no significant
difference in the mean baseline
DMFS values between the
experimental and control
groups. In both groups, the
baseline DMFS values for the
dropouts were higher than those
for the participants who
completed the study, but the
differences were not statistically
8 lost in experimental
group, 7 lost in control
group
After first exam:
16 lost in experimental
group, 15 lost in control
group
After second exam:
12 lost in experimental
group, 20 lost in control
group
21 in experimental
group missed the
second exam, and 15
in the control group
missed the second
exam.
135
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
significant.
Study sufficiently powered
(power calculations and
provide details): NR
Conclusion:
In the present study,
the children in the
experimental group
had significantly
smaller mean caries
increment than those in
the control group, the
preventive fraction
being 44.3%.
However, a huge effort
was made to achieve
the result. In the followup period, during visits
to dental hygienists,
the children in the
experimental group
received on average
11.4 applications of
fluoride varnish or a
mixture of fluoride and
chlorhexidine
varnishes, which was
over 7 times more than
the mean number of
fluoride varnish
applications in the
control group.
Counselling sessions
were over 3 times more
frequent in the
experimental than in
the control group.
Xylitol and fluoride
136
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
lozenges were
distributed free of
charge to the children
in the experimental
group. In addition,
children in the
experimental group
were, like all other
children in Pori,
exposed to a
community-level
program of oral health
promotion that
continued throughout
the study.
In spite of intention to
control harmful
snacking among the
children in the
experimental group, no
difference between the
experimental and
control groups was
found in any of the selfreported dietary habits,
except for the use of
xylitol products, at the
end of the follow-up.
This disappointing
result indicates that it is
difficult to influence
established dietary
habits. The difference
between groups in the
use of xylitol and
137
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
fluoride lozenges was
expected since they
were given free of
charge to the children
in the experimental
group. Nor was there a
significant difference
between the groups in
the self-reported
frequency of
toothbrushing. At the
end of the follow-up,
however, the mean
percentages of index
sites with visible plaque
and gingival bleeding
were slightly lower in
the experimental than
in the control group,
but the differences
were not statistically
significant.
According to our
results, a regimen that
includes multiple
measures for
controlling dental
caries can significantly
reduce increment in
dental decay among
caries-active children
living in an area where
the overall level of
caries experience is
low. Costs were not
138
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
considered in the
current study, but a
further challenge will
be to design a regimen
that is not only
efficacious but also
cost-effective.
139
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: Holloway,
P.J. and Clarkson,
J. E.
Study design: The study was
conducted in 2 parts; a
quantitative investigation and
a qualitative enquiry. (p.318,
para.8).
Population the sample
was recruited from:
Dentists from North-West
England (p.318, para.8).
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author: NR
How sample was
recruited: General
practitioners working in
well-established, successful
practices in North-west
England to complete the
quantitative element. From
these 50, 21participated
within the qualitative and
then 20 participated within
the follow-up questionnaire.
(p.318 para. 9-10)
The audiotapes were analysed to detect
common responses for the adoption of
various practice policies. NR what
method was used to conduct this
analysis. (p.318, para.9).
Year: 1994
Citation: Holloway,
P.J. and Clarkson,
J.E. (1994) Cost:
benefit of
prevention in
practice,
International Dental
Journal, 44, 317322.
Country of study:
North-west
England
Research aims, objectives,
and questions: A study was
conducted of the views of
established, successful,
general dental practitioners
treating their child patients
under a capitation system of
remuneration, in order to
discover what preventive
procedures on which patients
they considered were of
benefit to their practices and
why. (p.318, para.5).
Quality Score (++,
+, or -)
+
Theoretical approach
[grounded theory, IPA etc]:
NR
State how data were
collected:
What method(s): The
quantitative study involved a
telephone interview with 50
dentists, all of whom were
general practitioners working
in well established, successful
practices. These interviews
lasted for about 15 minutes
requiring the dentists to give
‘yes-no’ answers to a series
How many participants
recruited: 50 dentists
(p.318, para.8)
Sample characteristics:
Age: NR
Sex: NR
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: NorthWest England
Occupation: NR
Education: NR
Socioeconomic position:
NR
Social capital: NR
Key themes and findings relevant to
this review [with illustrative quotes if
available]
All the dentists included within the study
thought that prevention in some form on
selected patients was of value to the
practice. The qualitative element of the
study gave 4 reasons for this:
 Good image for the practice.
Parents approved and
recommended the practice to
their friends and relatives thus
enhancing the reputation. One
dentist did say it could be a ‘loss
leader’.
 Secondly, others genuinely felt
that prevention, if carried out well
could be cost: effective when
compared with operative
dentistry.
 Thirdly they all agreed that
prevention increased job
satisfaction in dentists as they
Limitations identified by
review team:
No clear justification for the
research methodology has
been given.
Some information is
provided on data collection,
but this does not include
anything on data storage.
More information on the
size of individual discussion
groups and where they took
place would have been
useful.
The relationship between
the researcher and
participants is not described
and there is no information
on how the research was
introduced, even in the
discussion groups.
There is no information on
how long the dentists have
been qualified or what
areas they come from and
whether there are any
differences in terms of the
socio-economic
characteristics of the areas
140
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
of questions about their
practice policies on the matter
of preventative procedures.
From their answers a
‘preventative awareness
score’ was calculated for each
dentist, allowing comparisons
between different dentists in
different practices and
communities. (p.318, para.8).
The qualitative phase
involved 4 discussion group
sessions with 21of the same
dentists in an attempt to
discover in more depth the
reasons why they chose
these practice policies. The
discussions lasted for 90
minutes and were largely
unstructured allowing the
dentists to cover the topics
that they wished within the
limits of a topic guide. These
were tape-recorded. (p.318,
para.9).
In addition 20 of these
dentists were asked to
complete a further
questionnaire based on the
‘standard gamble’ technique
in an effort to persuade them
to place a definite risk upon
not performing the various
preventive techniques. (p.318,
para.10).
Population and Sample
Selection
Inclusion criteria:
Practices within the NorthWest of England which
were well-established and
successful. (p.318, para.8)
Exclusion criteria: NR
Outcomes and Methods of Analysis

prefer to see child patients free
from dental caries rather than
having to restore their teeth as
they become diseased.
Finally, some dentists thought
that prevention was part of
modern philosophy, and that
dentists were neglectful if they
did not practice on their patients.
(p.318, para.11-13).
88% (44) of the dentists would prescribe
fluoride supplements but mainly on a
selective basis. They felt that those with
no caries and whose parents controlled
their children’s sugar intake did not need
tablets. Thus, 48% (24) restricted tablets
to children below the age of 10 years
with active caries and only in a
comprehensive preventive regimen.
Dentists were concerned that children
who took the tablets and brushed
regularly with fluoride toothpaste might
develop fluorosis later and that might be
detrimental to the practice, and therefore
some dentists halved the recommended
dose level in Britain before prescribing.
(p.319, para. 1).
Pit and fissure sealants were universally
popular among this group 96% (48)
although they were unsure of the cost:
effectiveness despite the fact that
several delegated this duty to the
hygienists. However they were popular
among dentists and parents if they felt
that something positive was being done
Notes by Review Team
they serve.
There is no discussion on
whether the methods that
were used were reliable.
Statistical tests have been
undertaken but it is not
clear what method was
used.
The qualitative element is
not rich at all. No extracts
are given and only very
broad themes are provided.
No mention on the reliability
of the analysis has been
mentioned, for example
how many researchers
coded the transcripts from
the qualitative element.
Findings from the
quantitative element are
clearly presented but as
noted above only very
broad findings are
presented for the qualitative
element.
Due to it being a pilot study
the further implications
have not been discussed.
Ethics have not been
referred to within the report.
141
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
By whom: NR
What setting: NR
When: NR
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
to prevent disease. Despite this few
would use it routinely (26%, 13) most
being selective in their application.
(p.319, para. 2).
Evidence gaps and/or
recommendations for
future research:
These dentists on the whole were not
confident in their ability to predict which
teeth caries would develop on in the next
year. Despite this 52% (26) said they
would seal the fissures of any teeth
which they thought would develop caries
within the next year. 54% (27) said that
they would be more inclined to seal the
fissures of first permanent molars on
eruption if they had been any caries in
the primary definition, and 52% (26)
would seal the remaining 3 teeth in a
series if one had already presented with
fissure caries. (p.319, para. 2-3).
This study is a pilot study
and it is planned to extend it
in order to investigate the
issue in a greater depth.
(p.320, para. 10).
Source of funding: NR
With regards to dietary counselling the
responses were ambivalent. Only 58%
(29) of dentists felt the offering of dietary
counselling was of benefit to the practice,
but these were very enthusiastic to the
extent that they felt the obligation to offer
it to most patients or the patient’s parent.
They felt that unless the sugar intake
was controlled the rest of the
preventative procedures would be to no
avail. However others felt that although
sugar intake in important it is very difficult
to change people’s eating patterns and
that many parents resented being told
that they were feeding their child
inadequately. (p.319, para. 4).
142
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Oral demonstrations were preferred by
the dentists (92%, 46) and thought that it
was of value to their practice; however
they were not really clear about their
reasoning. They felt that this was a
procedure which could be easily
arranged, particularly in referred to an
auxiliary staff member. (p.319, para.5).
Only 32% (16) of the dentists thought
that applying topical fluoride preparations
to the teeth of patients was of value to
the practice. (p.319, para.6).
Two-thirds (66%, 33) of those dentists
that though recommending the daily use
of fluoride mouthrinses was of some
value to the practice. These were part of
a preventive programme for adolescents
with high caries and for patients wearing
fixed appliances. (p.319, para.7).
52% (26) of the dentists employed
hygienists in their practices, many
delegated to these staff members for
procedures such as demonstrations,
dietary counselling and topical fluoride
treatments. Practices which employed
hygienists had a higher preventative
awareness score than those who did not
(p=.02). (p.319, para.8).
From the results of the ‘standard gamble’
exercise the most popular preventive
technique over the whole age range was
dietary counselling, with fissure sealants
a close second and oral hygiene being
143
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
third. Well behind these came fluoride
mouthrinsing, fluoride supplements and
professionally applied fluoride. (p.319,
para.9).
Statistical Analysis
Although there is mention of mean
scores and p-values they do not mention
which statistical test they have used.
Presumably they used the t-test but this
is not clear.
Conclusions:
It was clear from the responses that
factors other than immediate financial
considerations affected their decision on
whether or not to use preventative
techniques. Of particular relevance was
the image of their practice among
communities they served, and their own
job satisfaction which many valued as
highly as their cash flow. (p.320, para.3).
It was also clear that these dentists had
completely different working philosophy
to their peers in dental public health, as
their orientations are more focussed on
the dental health of each individual and
consequently they are less likely to
weigh the cost and benefits when the
treatment under consideration are of no
harm but may benefit the patient
themselves. (p.320, para.4).
Compared to dental public health
workers, dental practitioners do not
appear to be as concerned with
144
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
discovering the means of predicting
dental caries. (p.320, para.5).
Fissure sealants were also popular in
this group of dentists despite the
immediate cost: effectiveness being
unclear to them, however they were seen
as good practice builders. They preferred
to do sealant restorations rather than
sealing over the caries. (p.320, para.6).
The case for dietary counselling was
more complex. There were 2 groups
when it came to this matter, one group
felt that they had a professional
obligation to ensure that their patients
were informed of the threat of sugar in
the aetiology of dental caries to enable
them to take the necessary actions in
their everyday lives to avoid the disease.
The other group felt that there was very
little chance in being able to change the
individuals eating habits. (p.320, para.7).
145
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
Author: Anders
Hugoson, Dan
Lundgren, Babro
Asklow and Gun
Borglint
Source
Population(s):
Individuals aged
20-27 recruited
from 2 clinics – a
Large Public Dental
Service (PDS)
clinic, and from a
private two-dentist
practice in
Jonkoping, a city in
southern Sweden
with approximately
120,000
inhabitants.
Method of allocation (describe
how selected individuals/clusters
were allocated to intervention or
control groups – state if not
reported): No information is
provided on how randomisation
was achieved apart from that it
was carried-out by one of the
authors.
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective or
otherwise validated):
Oral health (clinical)
results:
1) Plaque Levels:
Limitations
identified by
author: No
limitations reported
Mean scores (with
standard deviations in
brackets)
Limitations
identified by
review team:
Group 11 (Control):
Full mouth – Baseline:
54.3 (21.9)
Full mouth - End point (3
years): 37.6 (24.3)
Proximal – Baseline: 41.6
(15.1)
Proximal - End point (3
years): 30.0 (18.9)
There is
considerable
ambiguity as both
papers report
different drop-out
rates even though
they are based on
the same study.
The drop-outs were
reported as "evenly
distributed"
between the groups
and whichever
paper is right the
drop-outs are
below <20%.
However the
ambiguity is clearly
a cause for alarm.
In addition, Paper
Two reported an
additional 13.5% of
drop-outs at the 5
year stage (Paper
One only goes to 3
years) and 9.8% at
Year: 2003 and
2007
Citation:
Hugoson, A., et al.,
Effect of 3 different
dental health
preventive
programmes on
young adult
individuals: a
randomised,
blinded, parallel
group, controlled
evaluation of oral
hygiene behaviour
on plaque and
gingivitis. Journal of
Clinical
Periodontology,
2007. 34(5): p. 40715. (Paper One)
Hugoson, A., et al.,
The effect of
different dental
health programmes
on young adult
Setting: A Large
Public Dental
Service (PDS)
clinic, and a private
two-dentist practice
in Jonkoping, a city
in southern
Sweden with
approximately
120,000
inhabitants. The
recruiting area of
the PDS clinic
comprised patients
from both urban
and rural areas
Location (urban or
rural): The
Report how confounding
factors were minimised: The
allocation was not concealed but
the Dental Hygienist who carried
out the baseline examination of
the patients and who also
examined the patients annually
was blinded to group assignment
and to the particular programmes
the patients were following.
Contamination was not explicitly
discussed and given that some
of the participants in different
groups probably went to the
same clinics it is possible.
However the focus of the study is
on different modes of delivery
rather than different messages
so it would be difficult to replicate
such experiences. Consequently
contamination is likely to be low.
Demographic imbalances at
baseline were not stated
NOTE: All study groups are
1) Outcome name:
Plaque levels
Outcome definition: Full
mouth number of tooth
surfaces with plaque and
proximal number of tooth
surfaces with plaque
Outcome measure:
Number of tooth surfaces
– mean numbers taken for
reporting purposes
Outcome measure
validated: Unclear
Unit of measurement:
Number of surfaces
Time points measured:
Baseline, 1 year, 2 year
and 3 year
2) Outcome name:
Gingivitis levels
Outcome definition: Full
mouth number of sites
with gingivitis and
proximal number of sites
with gingivitis
Group 21 (Karlstad 0):
Full mouth – Baseline:
63.0 (18.7)
Full mouth - End point (3
years): 12.9 (12.2)
Proximal – Baseline: 47.5
(11.6)
Proximal - End point (3
years): 10.4 (10.6)
Group 21 (Karlstad 1 and
2):
Full mouth – Baseline:
63.6 (17.7)
Full mouth - End point (3
years): 22.1 (21.1)
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Population and
setting
Method of allocation to
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Outcome definitions
and method of analysis
Results
Notes by review
team
individuals. A
longitudinal
evaluation of
knowledge and
behaviour including
cost aspects.
Swedish Dental
Journal, 2003.
27(3): p. 115-130.
(Paper Two)
recruiting area of
the PDS clinic
comprised patients
from both urban
and rural areas.
numbered on the basis of the
numbering system used in Paper
Two as this included all 8 study
groups. Sub-divisions of the
Karlstad group, which are
numbered in Paper One as “20”
and “Two1” etc are numbered
here as “Karlstad 0”, “Karlstad 1”
etc so as to avoid confusion with
the second set of study groups
that appear only in Paper Two.
Outcome measure:
Number of sites – mean
numbers taken for
reporting purposes
Outcome measure
validated: Unclear
Proximal – Baseline: 47.8
(11.5)
Proximal - End point (3
years): 18.4 (18.3)
the 10 year stage altogether this
clearly surpasses
the 20% level.
Group 31 (Individual
Educational):
Full mouth – Baseline:
60.7 (22.8)
Full mouth - End point (3
years): 24.5 (23.6)
Proximal – Baseline: 45.0
(14.0)
Proximal - End point (3
years):20.2 (19.8)
Information on
location, population
and urban/rural
split but no
demographic
breakdown of the
area. It would have
been useful to
know how many
20-27 year olds
there were
Country of study:
Sweden
Aim of Study:
Paper One:
To evaluate, in
young adults, the
effect of different
preventive
programmes on
oral hygiene and to
determine whether
the variables
investigated are
predictors of
gingival health.
Paper Two:
The goal of this
study was to report
the long-term effect
of different dental
health programmes
on young adult
Sample
characteristics:
Age: 20-27
Sex: 211 men and
189 women
Sexual
orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of
residence: NR
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
Eligible
population
(describe how
individuals, groups,
or clusters were
recruited, e.g.
media
advertisement,
class list, area):
Individuals were
First set of study groups (first
3 years, Papers One and Two):
Control Group 11:
What was delivered: The
individuals in this group
underwent no organised
prophylactic measures for caries
gingivitis/periodontitis within the
framework of the study but had
to answer a questionnaire about
knowledge of dental diseases
and oral hygiene behaviour. The
subjects were recalled at 12month intervals for follow-up
examinations, identical to the
baseline examination, over the
next 3 years
By whom: Dental Hygienist
To whom: 100 patients
How delivered: N/A.
When/where: Dental clinic
How often: Follow-up every 12
months
Unit of measurement:
Number of sites
Time points measured:
Baseline, 1 year, 2 year
and 3 year
3) Outcome name:
Knowledge of the 2 most
common dental diseases
Outcome definition:
What are the 2 most
common diseases that
affect the teeth? (Open
question) The answer was
considered correct only
when both caries and
gingivitis/periodontitis
were named.
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
Unit of measurement:
Open question – coded as
correct or incorrect
Time points measured:
Group 41 (Group
Education):
Full mouth – Baseline:
59.2 (23.1)
Full mouth - End point (3
years): 21.6 (20.9)
Proximal – Baseline: 44.5
(15.0)
Proximal - End point (3
years): 16.5 (15.3)
Full mouth:
After 3 years the
presence of plaque
decreased (p<0.05).
Group 11 had more
plaque (p<0.05) than the
test groups. The
differences between the
Outcome measures
in Paper One were
clinical. The
outcomes in Paper
Two were patient
reported and no
test appeared to
have been made
for reliability.
There is a lack of
information on the
results of a
question on dental
cleaning aids.
Other than that all
outcomes seem to
have been
reported.
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
individuals’
knowledge and
behaviour relative
to oral health.
offered (via a
written invitation) a
dental examination
free of charge and
were then
contacted by
telephone. Patients
were summoned
consecutively until
200 individuals
from each clinic
had replied.
How long for: 3 years
Baseline, 1 year, 3 year, 5
year and 10 years
test groups were
statistically nonsignificant.
Study Design:
Randomised,
blinded, parallel,
controlled clinical
study
Quality Score (++,
+, or -): +
However
inconsistency in
drop-out rates
between Papers
One and Two is a
serious issue and
suggests that
caution should be
treated when
interpreting any of
these results.
External
Validity(++, +, or ): ++
State if eligible
population is
considered by the
study authors as
representative of
the source
population: NR
Inclusion Criteria:
Individual was not
planning to move
from Jonkoping in
the next few years
Exclusion
Criteria: NR
% of selected
individuals agreed
to participate: NR
– there is no data
on refusals even
though the
Group 21 The “Karlstad
Model”:
What was delivered: In this
group, all individuals received
prophylactic care every second
month (6 times per year)
according to the Karlstad model
for adult individuals. At the first
visit, information on caries and
gingivitis/periodontitis was
presented and oral hygiene
instruction was given based on
plaque disclosure. At the next
five visits, at 2-month intervals,
the individual’s oral status was
reviewed and, when necessary,
information or oral hygiene
instruction was repeated.
Half the number of the
individuals was also randomly
chosen to have no other
preventive measures (Karlstad
0). The other individuals were
randomly chosen to undergo
professional tooth cleaning at
each visit. The cleaning was
performed crosswise in 2
quadrants, which meant that the
teeth in the right maxilla and the
left mandible were professionally
cleaned in 25 individuals
(Karlstad 1) and in the left
maxilla and the right mandible in
4) Outcome name:
Knowledge of the causes
of caries
Outcome definition:
What causes carries?
(open question) The
answer was considered
correct when both
bacteria and diet were
named.
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
Unit of measurement:
Open question – coded as
correct or incorrect
Time points measured:
Baseline, 1 year, 3 year, 5
year and 10 years
5) Outcome name:
Knowledge of the causes
of gingivitis/periodontitis
Outcome definition:
What causes
gingivitis/periodontitis?
(open question) Bacterial
plaque or poor oral
hygiene was considered
correct.
Proximal:
After 3 years: in all
groups the presence of
plague decreased
(p<0.05). The difference
between group Karlstad 0
and group 11 as well as
between Karlstad 0 and
groups Karlstad 1and2,
group 31, and 41 was
statistically significant
(p<0.05). The difference
between group 11 and
Karlstad 1and2, group 31,
and 41 was statistically
significant (po0.05). The
difference between group
Karlstad 1and2, group 31,
and 41 was statistically
non-significant.
2) Gingivitis Levels:
Mean scores (with
standard deviations in
brackets)
Group 11 (Control):
Full mouth – Baseline:
33.2 (19.5)
Full mouth - End point (3
Notes by review
team
Power was not
stated and the
effect size was not
given. No
confidence
intervals were
reported in Paper
One. P values were
reported in both
papers.
Sex and smoking
habits were
controlled for in
Paper One's
logistic regression
model but because
demographic
characteristics are
not given it isn't
clear whether any
other variables
(such as education)
should have been
included.
Participants
dropped-out in
different years and
it isn't clear how
this was dealt with
in the analysis
which is a flaw
particularly when
looking at the 5
year and 10 year
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
recruitment process
suggests there
were some
25 individuals (Karlstad 2). The
1-year follow-up comprised the
same measures undertaken at
the baseline examination. The
remedial measures undertaken
during the first year were
repeated for the next 2 years
with yearly follow-ups, the last
one being the 3-year follow-up
Theoretical basis: N/A
By whom: The examinations
were conducted by the
authors, 2 experienced dental
hygienists, and 2 dentists.
To whom: 100 participants
How delivered: Information on
caries and gingivitis/periodontitis
was presented and oral hygiene
instruction was given
When/where: Dental clinic
How often: Follow-up every 12
months
How long for: 3 years
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
years): 28.5 (17.0)
Proximal – Baseline: 27.6
(14.3)
Proximal - End point (3
years): 23.8 (13.1)
results in Paper
Two.
Potential sources
of bias: NR
Group 31 Individual
Educational:
What was delivered: In this
group, the individuals each
underwent an individual basic
preventive programme according
to the National Swedish Board of
Health and Welfare. The
programme comprised 3 visits at
2-week intervals the first year. At
the first visit information on
caries and gingivitis/periodontitis
Unit of measurement:
Open question – coded as
correct or incorrect
Time points measured:
Baseline, 1 year, 3 year, 5
year and 10 years
6) Outcome name:
Knowledge of the most
important part of the tooth
to clean
Outcome definition:
Which part of the tooth is
the most important to
clean? (open question)
The “correct” response
was considered to be
either between the teeth
and at the edge of the
gingival margin, between
the teeth, or at the edge
of the gingival margin.
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
Unit of measurement:
Open question – coded as
correct or incorrect
Group 21 (Karlstad 0):
Full mouth – Baseline:
40.4 (16.5)
Full mouth - End point (3
years): 15.0 (12.1)
Proximal – Baseline: 33.5
(11.7)
Proximal - End point (3
years): 13.3 (10.2)
Group 21 (Karlstad
1and2):
Full mouth – Baseline:
46.7 (23.4)
Full mouth - End point (3
years): 20.6 (19.7)
Proximal – Baseline: 36.3
(14.4)
Proximal - End point (3
years): 16,3 (14.5)
Group 31 (Individual
Educational):
Full mouth – Baseline:
38.8 (22.1)
Full mouth - End point (3
years):19.4 (17.4)
Proximal – Baseline: 31.9
(16.3)
Proximal - End point (3
Evidence gaps:
The model of
preventive work
long discussed is
the possibility to
influence dental
health positively
using preventive
measures directed
to the whole
population, that is
basic prevention
programmes, and
then offering
additional
prophylaxis to
individuals with a
high or progressing
dental disease
activity, Basic
factors in these
strategies are the
focus on fluorides,
dietary counselling,
and improvement in
oral hygiene. These
measures bring
about both the
chance to maintain
health and a way of
fighting disease, A
high-risk approach
where individuals
149
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Study details
Population and
setting
Method of allocation to
intervention/control
was presented and oral hygiene
instruction was given based on
plaque disclosure. The
individual’s oral status was
reviewed at the next 2 visits. The
1-year follow-up comprised the
measures undertaken at the
baseline examination. Directly
after the follow-up, the
individuals were scheduled for a
repetition of indicated
information and oral hygiene
instruction. The same was done
at the 2-year follow-up, after
which the individuals were called
for a 3-year follow-up.
Theoretical basis: N/A
By whom: The examinations
were conducted by the authors,
2 experienced dental hygienists,
and 2 dentists.
To whom: 100 participants
How delivered:
When/where: Dental clinic
How often: Follow-up every 12
months
How long for: 3 years
Group 41 Group Educational:
What was delivered: The
individuals in this group
underwent the remedial
measures recommended by the
National Swedish Board of
Health and Welfare for
dentalhealth preventive
Outcome definitions
and method of analysis
Time points measured:
Baseline, 1 year, 3 year, 5
year and 10 years
7) Outcome name: Do
you clean the area
between your teeth?
Outcome definition: Do
you clean the area
between the teeth? The
alternatives were yes or
no.
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
Unit of measurement:
Yes or no – responses to
question
Time points measured:
Baseline, 1 year, 3 year, 5
year and 10 years
8) Outcome name: What
aids do you use to clean
your teeth approximately?
Outcome definition:
What aids do you use to
clean your teeth
approximately? Open
question if the respondent
answered yes to the
previous question
Results
Notes by review
team
years):16.6 (14.2)
Full mouth:
After 3 years: in all
groups the number of
sites with gingivitis
decreased (p<0.05).
Group 11 had statistically
significant more sites with
gingivitis (p<0.05) than
the other groups. The
differences between the
test groups were
statistically nonsignificant.
are identified by
screening has also
been suggested.
However high-risk
strategies for
controlling dental
diseases have
been questioned
and it has been
proposed that a
population
approach will
provide virtually the
same prevention
effect with less
effort and lower
cost (Hausen et al
2000, Sheiiham
and Watt 2003).
Loe (2000) and
Van Loveran
(2000) have called
attention to the role
of plaque as a
common factor in
preventing these
diseases.
Proximal:
After 3 years: in all
groups the number of
sites with gingivitis
decreased (p<0.05).
Group 11 had statistically
significant more sites with
Concerning costs it
is mainly the direct
expenses of the
dental clinic that
became lower in
comparison with
the chair-conducted
programmes. The
Group 41 (Group
Education):
Full mouth – Baseline:
36.3 (18.2)
Full mouth - End point (3
years): 20.5 (16.6)
Proximal – Baseline: 30.1
(14.3)
Proximal - End point (3
years): 17.3 (12.9)
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
programmes for adults but
modified for group-based
information with 3 visits that had
essentially the same content as
the programme followed by
group 3. The programme was
conducted as group activities
with 10 individuals in each
group.
Theoretical basis: N/A
By whom: The examinations
were conducted by the authors,
2 experienced dental hygienists,
and 2 dentists.
To whom: 100 participants
How delivered:
When/where: Dental clinic
How often: Follow-up every 12
months
How long for: 3 years
(outcome 7)
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
gingivitis (p<0.05) than
the other groups. The
difference between the
test groups were
statistically nonsignificant
patients’ costs can
also be reduced if
the group-based
activity takes place
somewhere else
than in the clinic.
This also paves the
way for new
research on how to
disseminate a
health message
using modern
technology.
Study groups for additional 2
years intervention and final (10
year) follow-up (Paper Two
only):
9) Outcome name: Mean
number of snacks per day
Outcome definition:
“How often do you eat or
drink between meals”
(question to patient)
Outcome measure:
Patient reported
Outcome measure
validated: Unclear
NOTE: These groups, which
replaced the groups outlined
above when the initial 3 year
treatment period ended, are not
based on randomisation but on
previous group allocation and on
gingival and carries status.
Group 12:
What was delivered: Individuals
Unit of measurement:
Open question – coded as
correct or incorrect
Time points measured:
Baseline, 1 year, 3 year, 5
year and 10 years NOTE:
This data was not
reported in full (i.e. for
each year and group) and
it was an additional
question if respondents
said “yes” to the previous
question.
Unit of measurement:
Number of times.
Alternatives ranged from
0 to 10 and then more
After 3 years, the gingival
status of 30 individuals in
group 11, none in
Karlstad 0, 4 in Karlstad
1and2, 12 in group 31,
and 18 in group 41 was
impaired.
Regression model:
A multiple logistic
regression analysis with
a forward stepwise
selection of variables was
performed to detect
variables of importance
to gingival health. The
statistical analysis
showed that a good
gingival status at
baseline was the most
important predictor for a
healthy gingival status
after 3 years (odds ratio:
1.076, CI:1.055-1.099,
p<0.001).
Participation in one of the
3 preventive programmes
and knowledge of the 2
Source of
funding: Financial
support for this
study was given by
Jonkoping County
Council and the
Institute for
Postgraduate
Dental Education,
Jonkoping,
Sweden.
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Method of allocation to
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Outcome definitions
and method of analysis
Results
who had <20% gingivitis at this
time underwent no prophylactic
measures and were only given
information after the 3 year
follow-up. Individuals who had
>20% gingivitis or were in need
of supplementary prophylaxis
underwent basic prophylaxis (3
visits according to the previous
model for group 3).
Theoretical basis: N/A
By whom: The examinations
were conducted by the authors,
2 experienced dental hygienists,
and 2 dentists (94 participants at
4 year follow-up and 85 at five
year follow-up).
To whom: The individuals in this
group had previously not
received any form of basic
prophylaxis during the study’s
first 3 years.
How delivered: individual-based
information
When/where: Dental clinic
How often: Follow-up every 12
months until treatment period
ends.
How long for: 2 years after
group reassignment (last followup was 7 years after
reassignment or 10 years after
study began)
than 10 times a day
major dental diseases
caries and gingivitis or
periodontitis were also
statistically significant
variables.
Karlstad 0: OR: 0.034,
CI: 0.010-0.121, P<0.001
Karlstad 1/2: OR: 0.046,
CI: 0.013-0.160, P<0.001
Group 31: OR: 0.066, CI:
0.023-0.184, P<0.001
Group 41: OR: 0.191, CI:
0.073-0.497, P=0.001
Group 22:
What was delivered: All
Time points measured:
Baseline, 1 year, 3 year,
and 5 years
Method of analysis
(indicate if ITT or
completer analysis was
used and if adjustments
were made for any
baseline differences in
important confounders):
There is no mention of
ITT being undertaken.
For the clinical measures
(plaque and gingivitis
levels) one-way ANOVA
was used to make
comparisons between
groups and between
examination sessions. In
addition a multiple logistic
regression model was
used to find the model of
gingival health with the
best overall fit. The
dependent variable
‘‘gingival health’’ was
defined as a dichotomous
variable according to the
individual full-mouth GI
where a value50
Notes by review
team
Behavioural results:
3) Knowledge of the 2
most common dental
diseases:
% of participants (actual
number in brackets)
Group 11 (Control):
Baseline: 58 (57)
1 year: 61 (59)
3 year: 79 (74)
Group 21 (Karlstad):
Baseline: 49 (48)
1 year: 81 (79)
3 year: 86 (78)
Group 31 (Individual
Educational):
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Method of allocation to
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and method of analysis
Results
individuals in this group had
undergone basic prophylaxis
comprising visits every second
month for 3 years. Therefore,
only the individuals who were in
need of supplementary
underwent additional
prophylaxis. This occurred as an
individual supplementary
programme. The other
individuals were offered no
additional prophylaxis and only
received information after the 3year follow-up, independent of
whether they had >20% gingivitis
or <20% gingivitis.
Theoretical basis: N/A
By whom: The examinations
were conducted by the authors,
2 experienced dental hygienists,
and 2 dentists.
To whom: All individuals in this
group had undergone basic
prophylaxis comprising visits
every second month for 3 years
(93 participants at 4 year followup and 83 at five year follow-up).
How delivered: individual-based
information – not clear whether
this was different to intervention
group 3 or not
When/where: Dental clinic
How often: Follow-up every 12
months until treatment period
ends.
How long for: 2 years after
comprised one-third of the
individuals with the lowest
GI scores and a value51
comprised one-third of the
individuals with the
highest GI scores.
Baseline: 52 (52)
1 year: 72 (71)
3 year: 74 (70)
For the behavioural
outcomes chi-square was
used to test significance
across study groups on a
cross-sectional basis, as
well as to test significance
within groups on a
longitudinal basis. In the
case of 2 behavioural
outcomes (“mean number
of snacks per day” and
“What aids do you use to
clean your teeth
approximately?”) no
statistical tests appear to
have been undertaken.
Notes by review
team
Group 41 (Group
Education):
Baseline: 59 (58)
1 year:76 (74)
3 year: 86 (79)
Group 12:
5 year: 76 (63)
10 year: 96 (84)
Group 22:
5 year: 90 (77)
10 year: 91 (84)
Group 32:
5 year: 79 (71)
10 year: 89 (83)
Group 42:
5 year:88 (76)
10 year: 89 (78)
Longitudinal comparison
– results significant at
p<0.05:
 Group 1i 1 year 3 years
 Group 2i baseline
– 1 year
 Group 3i baseline
– 1 year
 Group 4i baseline
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Population and
setting
Method of allocation to
intervention/control
group reassignment (last followup was 7 years after
reassignment or 10 years after
study began)
Group 32:
What was delivered: All the
individuals in this group had also
undergone basic prophylaxis
previously. Therefore only the
individuals who were in need of
supplementary prophylaxis
underwent additional
prophylaxis. This occurred as an
individual supplementary
programme. The other
individuals underwent no
prophylaxis and only received
information after the 3-year
follow-up, independent of
whether they had >20% gingivitis
or <20% gingivitis.
Theoretical basis: N/A
By whom: The examinations
were conducted by the authors,
2 experienced dental hygienists,
and 2 dentists.
To whom: (93 participants at 4
year follow-up and 89 at five
year follow-up)
How delivered: individual-based
information – not clear whether
this was different to intervention
group 3 or not
When/where: Dental clinic
How often: Follow-up every 12
Outcome definitions
and method of analysis
Results
Notes by review
team
– 1 year
Group comparison –
results significant at
p<0.05:
 1 year; 11 – 21
 1 year; 11 - 41
 5 years; 1ii-4ii
 5 years; 1ii-2ii
4) Knowledge of the
causes of caries
% of participants (actual
number in brackets)
Group 11 (Control):
Baseline: 25 (25)
1 year: 30 (29)
3 year: 42 (39)
Group 21 (Karlstad):
Baseline:25 (25)
1 year: 39 (38)
3 year: 54 (50)
Group 31 (Individual
Educational):
Baseline: 33 (33)
1 year: 45 (44)
3 year: 45 (42)
Group 41 (Group
Education):
Baseline: 24 (24)
1 year: 35 (34)
3 year: 43 (40)
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Method of allocation to
intervention/control
months until treatment period
ends.
How long for: 2 years after
group reassignment (last followup was 7 years after
reassignment or 10 years after
study began)
Group 42:
What was delivered: All
individuals in this group had
undergone basic prophylaxis on
a group basis. Therefore
individuals who had >20%
gingivitis or were in need of
supplementary prophylaxis
underwent the same basic
prophylaxis as group 31 had
previously (3 visits). Individuals
who had <20% gingivitis at this
time were offered no prophylactic
measures and only received
information after the 3-year
follow-up.
Theoretical basis: N/A
By whom: The examinations
were conducted by the authors,
2 experienced dental hygienists,
and 2 dentists.
To whom: All individuals in this
group had undergone basic
prophylaxis on a group basis.
(93 participants at 4 year followup and 89 at five year follow-up)
How delivered: essentially the
same content as the programme
Outcome definitions
and method of analysis
Results
Notes by review
team
Group 12:
5 year: 42 (35)
10 year: 63 (55)
Group 22:
5 year: 49 (43)
10 year: 70 (64)
Group 32:
5 year: 43 (39)
10 year: 70 (65)
Group 42:
5 year: 43 (37)
10 year: 56 (49)
Longitudinal comparison
– results significant at
p<0.05:
 Group 2i baseline
– 1 year
 Group 2i 1 year –
3 years
Group comparison –
results significant at
p<0.05:
 1 year; 11 – 31
5) Knowledge of the
causes of
gingivitis/periodontitis
% of participants (actual
number in brackets)
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Population and
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Method of allocation to
intervention/control
followed by group 3
When/where: Dental clinic
How often: Follow-up every 12
months until treatment period
ends.
How long for: 2 years after
group reassignment (last followup was 7 years after
reassignment or 10 years after
study began)
Sample size at baseline:
Total sample N = 400
Group 11 (Control) N = 100
Group 21 (Karlstad)1 N = 100
(incl. 50 in Karlstad 0 and 50 in
Karlstad 1 and 2
Group 31 (Individual
Educational)1 N = 100
Group 41 (Group Educational)1
N = 100
Sample sizes for second set of
groups (NOTE: it is not
absolutely certain this was initial
number allocated to each group
at baseline (3 year stage) as the
earliest information we have is
for the 4 year follow-up):
Group 12 N (4 Year) = 94 (58
received prophylaxis; 36 no
prophylaxis)
Group 12 N (5 Year) = 85 (7
received prophylaxis; 78 no
Outcome definitions
and method of analysis
Results
Notes by review
team
Group 11 (Control):
Baseline:59 (54)
1 year: 54 (49)
3 year: 40 (37)
Group 21 (Karlstad):
Baseline:54 (51)
1 year: 57 (54)
3 year: 68 (62)
Group 31 (Individual
Educational):
Baseline: 58 (50)
1 year: 65 (63)
3 year: 55 (51)
Group 41 (Group
Education):
Baseline: 61 (54)
1 year: 53 (48)
3 year: 61 (57)
Group 12:
5 year: 58 (48)
10 year: 68 (59)
Group 22:
5 year: 77 (66)
10 year: 79 (73)
Group 32:
5 year: 73 (66)
10 year: 76 (71)
Group 42:
5 year: 73 (61)
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Population and
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Method of allocation to
intervention/control
prophylaxis)
Group 22 N (4 Year = 93 (13
received prophylaxis; 80 no
prophylaxis)
Group 22 N (5 Year) = 83 (20
received prophylaxis; 63 no
prophylaxis)
Group 32 N (4 Year) = 93 (12
received prophylaxis; 81 no
prophylaxis)
Group 32 N (5 Year) = 89 (8
received prophylaxis; 81 no
prophylaxis)
Group 42 N (4 Year) = 93 (39
received prophylaxis; 54 no
prophylaxis)
Group 42 N (5 Year) = 89 (21
received prophylaxis; 68 no
prophylaxis)
Baseline comparisons (report
any baseline differences
between groups in important
confounders): NR
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of analysis
Results
Notes by review
team
10 year: 72 (63)
Longitudinal comparison
– results significant at
p<0.05:
 Group 1ii 3 year –
5 years
 Group 3ii 3 year –
5 years
Group comparison –
results significant at
p<0.05:
 3 years; 11 – 21
 3 years; 11-41
 5 years; 1ii-2ii
 5 years; 1ii-3ii
6) Knowledge of the
most important part of
the tooth to clean
% of participants (actual
number in brackets)
Group 11 (Control):
Baseline: 64 (64)
1 year: 73 (71)
3 year: 75 (70)
Group 21 (Karlstad):
Baseline: 64 (64)
1 year: 86 (82)
3 year: 87 (81)
Group 31 (Individual
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Method of allocation to
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Outcome definitions
and method of analysis
Results
Notes by review
team
Educational):
Baseline: 69 (68)
1 year: 80 (78)
3 year: 86 (80)
Group 41 (Group
Education):
Baseline: 67 (67)
1 year: 87 (85)
3 year: 90 (85)
Group 12:
5 year:83 (69)
10 year: 86 (76)
Group 22:
5 year: 87 (76)
10 year: 92 (85)
Group 32:
5 year: 83 (75)
10 year: 91 (85)
Group 42:
5 year: 88 (76)
10 year: 84 (74)
Longitudinal comparison
– results significant at
p<0.05:
 Group 2i baseline
– 1 year
 Group 4i baseline
– 1 year
Group comparison –
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Population and
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Method of allocation to
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Outcome definitions
and method of analysis
Results
Notes by review
team
results significant at
p<0.05:
 1 year; 11 – 41
 3 years; 11-21
 3 years; 11-41
7) Do you clean the
area between your
teeth?
% of participants (actual
number in brackets)
Group 11 (Control):
Baseline:51 (51)
1 year: 57 (54)
3 year: 64 (68)
Group 21 (Karlstad):
Baseline: 57 (57)
1 year: 98 (95)
3 year: 97 (89)
Group 31 (Individual
Educational):
Baseline: 47 (46)
1 year: 91 (89)
3 year: 92 (85)
Group 41 (Group
Education):
Baseline: 57 (57)
1 year: 88 (86)
3 year: 93 (86)
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
Group 12:
5 year: 87 (71)
10 year: 70 (62)
Group 22:
5 year: 95 (83)
10 year: 70 (64)
Group 32:
5 year: 91 (82)
10 year: 63 (58)
Group 42:
5 year: 90 (77)
10 year: 67 (59)
Longitudinal comparison
– results significant at
p<0.05:
 Group 2i baseline
– 1 year
 Group 3i baseline
– 1 year
 Group 4i baseline
– 1 year
 Group 1ii 3 years
– 5 years
Group comparison –
results significant at
p<0.05:
 1 year; 11 – 21
 1 year; 11 - 31
 1 year; 11 - 41
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and method of analysis
Results




Notes by review
team
1 year; 21 - 41
3 years; 11-21
3 years; 11-31
3 years; 11-41
8) What aids do you
use to clean your teeth
approximately?
Both toothpicks and
dental floss were used
equally as aids for
approximal cleaning at
the baseline examination
in all groups. A significant
shift to dental floss as the
primary aid occurred in
the test groups after 1
year. When prophylactic
measures were begun in
group 1 after 3 years, the
same change in favour of
dental floss also occurred
as approximal cleaning
increased. This
distribution between
toothpicks and dental
floss remained at the 10
year follow-up.
9) Mean number of
snacks per day
Mean scores (no
standard deviations are
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
reported in the paper).
This outcome was not
measured at Year 10.
Group 11 (Control):
Baseline: 4.4
1 year: 3.8
3 year: 3.8
Group 21 (Karlstad):
Baseline: 4.0
1 year: 3.8
3 year: 3.5
Group 31 (Individual
Educational):
Baseline: 4.0
1 year: 4.0
3 year: 3.6
Group 41 (Group
Education):
Baseline: 4.4
1 year: 4.2
3 year: 4.1
Group 12:
5 year: 3.7
Group 22:
5 year: 3.4
Group 32:
5 year: 3.8
Group 42:
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Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
5 year: 4.0
Attrition details:
Indicate the number lost
to follow up and whether
the proportion lost to
follow-up differed by
group (i.e. intervention vs
control)
Paper Two indicates that
the drop-out rates during
the study’s first 3 years
were 1% (4 individuals),
1.8% (7 individuals) and
3.8% (15 individuals)
after 1,2 and 3 years
respectively, in total 6.5%
(26 individuals). The
main reason for the dropouts during these 3 years
was moving from the
area 4% (16 individuals),
economic reasons 0.5%
(2 individuals), lack of
interest 1.75% (7
individuals) and
deceased 0.25% (1
individual). The drop-outs
were evenly distributed
between the groups. At
the 5 year follow-up the
drop-out rate was 13.5%
(54 individuals) and at
the 10 year follow-up
9.8% (39 individuals).
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Method of allocation to
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and method of analysis
Results
Notes by review
team
Conclusion:
Paper One
The present paper
demonstrates the effect
of the same programmes
on the oral health
behaviour of the
participants in the test
groups, recorded as
changes in the presence
of plaque and gingivitis.
In all test programmes,
the full-mouth and
proximal presence of
plaque and gingivitis
decreased significantly
on the group level in
relation to the control
group. However, the
control group was also
affected positively
concerning levels of
plaque and gingivitis.
One probable
explanation may be
improved awareness of
the subjects taking part in
a study with regular
annual clinical
examinations and the use
of questionnaires that
bring issues on dental
health up to date.
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
The greatest
improvement was found
in the group who visited
the dentist for individual
information and
instruction in oral hygiene
every second months.
Professional tooth
cleaning provided no
clinical benefit beyond
that derived from
individual and groupbased health education.
The statistical analysis
showed that the variables
‘‘gingival health at
baseline’’, ‘‘belonging to
one of the test
programmes’’, and
‘‘knowledge of both
caries and gingivitis or
periodontitis’’ were the
best predictors of good
oral health.
Paper Two
The preventive measures
that targeted the
individual-based on
previously received
prophylaxis and the
individual’s symptoms
and were begun after 3
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of analysis
Results
Notes by review
team
years had no effect on
knowledge in some of the
test groups. Neither was
the level of approximal
cleaning affected most
likely because of the high
level already achieved. It
should be noted
however, than in years 4
and 5 only 23% and 18%
respectively of all the
individuals in the 3 test
groups underwent
additional preventive
measures. Dietary
behaviour was also
unaffected in these
years.
It was possible not only
to affect oral hygiene
behaviour positively but
also to maintain this
affect over a 5 year
period when monitoring
of the type used in the
study ceased, however
behaviour deteriorated.
At the 10 year follow-up,
that is 5 years after the
study had actually ended,
reported approximal
cleaning had deteriorated
to 68% of all individuals.
On the other hand an
increase in knowledge
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Method of allocation to
intervention/control
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and method of analysis
Results
Notes by review
team
was reported. Preventive
work should
consequently focus on
behaviour by
concentrating on patientcentred attitudes.
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setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Humphris,
G.M., R.S. Ireland,
and E.A. Field
Source
Population(s):
Practices were
selected from areas
of the north west of
England that were
situated in a wide
ranging set of
localities.
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): Pseudo
randomisation - whole sessions
were allocated to either group.
Baseline imbalances were
inspected and found not to be
significant with the exception of
gender. Gender was controlled
for in the analysis.
Outcomes (include
details of all relevant
outcome measures
and whether measures
are objective or
subjective or otherwise
validated):
For each outcome
report
Limitations identified
by author:
1) Knowledge of oral
cancer
Paper One:
Criticism has been
levelled at studies
which attempt to
assess the effect of
leaflets when it is not
clear whether the
leaflet has been read,
e.g. [22]. Admittedly,
the present study can
only show the
immediate effects on
knowledge of oral
cancer and further
work is required to
determine any longerterm benefits.
Year: 2001 (Papers
One and Two) 2004
(Paper Three)
Citation: Humphris,
G.M., R.S. Ireland,
and E.A. Field,
Immediate
knowledge increase
from an oral cancer
information leaflet in
patients attending a
primary healthcare
facility: a
randomised
controlled trial. Oral
Oncology, 2001.
37(1): p. 99-102.
(Paper One)
Humphris, G.M.,
R.S. Ireland, and
E.A. Field,
Randomised trial of
the psychological
effect of information
about oral cancer in
primary care
settings. Oral
Oncology, 2001.
Setting: Practices
were selected from
areas of the north
west of England that
were situated in a
wide ranging set of
localities. Deprivation
has been highlighted
as a key variable in
predicting various
aspects of oral health.
The Townsend
indices associated
with the locality from
which the practice
resided were derived
at ward level, from
the 1991 Census of
Population Local
Base Statistics,
accessed via the
Manchester
Computing Centre. A
positive score
denotes greater
Report how confounding
factors were minimised:
Contamination would have
been minimised as
randomisation was by group,
while analysis to remove the
possibility of variables
confounding interpretation was
conducted. However the
allocation was not concealed
and there does not appear to
have been any blinding.
Programme/Intervention
description:
What was delivered: Patients
were given the leaflet and
instructed to read the content.
Then the leaflet was collected
and the patient was handed the
Outcome name: 1)
Knowledge of oral
cancer
Outcome definition:
Knowledge of items in
questionnaire
Outcome measure:
Questionnaire
response
Outcome measure
validated: Yes
Unit of measurement:
Correct or incorrect
answers
Time points
measured: End of
intervention
Outcome name: 2)
Intention to have a
screen for oral cancer
Outcome definition:
Participants were
asked in the
questionnaire about
Results by dental or
medical setting – mean
score with 95%
confidence intervals in
brackets:
Intervention group:
Dental: 30.74 (30.1531.33)
Medical: 29.52 (28.8930.16)
Control group:
Dental: 25.68 (25.0726.28)
Medical: 24.66 (24.0025.31)
Knowledge levels of
oral cancer were
greater by 5 points in
those who received the
leaflet: F[1,739]=
246.24, P<0.0001).
Levene's test of
homogeneity of
variance across groups
confirmed that the
effect shown by the
The result does not
exclude the possibility
of setting being part
responsible for the
longer-term retention
of information. It had
been expected that
patients reading the
leaflet in a dental
waiting area may have
strengthened their
interest in the topic of
oral cancer.
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Method of allocation to
intervention/control
37(7): p. 548-52.
(Paper Two)
deprivation. The
mean and standard
deviation of the index
compiled from the 14
wards associated with
the practices sampled
was 3.92 and 4.24,
respectively. The
equivalent values for
Merseyside were 3.68
and 4.56.
questionnaire sheet for
completion. Patients completed
the questionnaire
Theoretical basis: N/A
By whom: Trained interviewers
recruited participants and gave
out the leaflet
To whom: Half the sample
(400)
How delivered: All information
was written in the leaflet. The
framing was partly negative,
with mention of mortality rates.
The leaflet possessed a
moderately easy reading level
according to the Flesch
reliability index. An A4 glossy
paper design was used and
factual information was aided
by bullet points
When/where: Dental practices
and medical practices
How often: Once
How long for: One day
Humphris, G.M. and
E.A. Field, An oral
cancer information
leaflet for smokers in
primary care: results
from 2 randomised
controlled trials.
Community
Dentistry and Oral
Epidemiology, 2004.
32(2): p. 143-9.
(Paper Three)
[NOTE: This paper
also reports results
from a separate
study – these are
dealt with in a
separate evidence
table - Humphris et
al 2003]
Country of study:
England
Aim of Study: To
determine the
immediate influence
of a validated patient
information leaflet
(PIL) in patient
anxiety and intention
to have a screen for
Location (urban or
rural): NR
Sample
characteristics:
Age: Mean age for
leaflet (intervention)
group = 43.96
Mean age for no
leaflet (control) group
= 43.31
Sex: % of female in
leaflet group = 54.6%
% of females in no
leaflet group = 62.3%
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Control/Comparator
description:
What was delivered: All
participants completed the
questionnaire. Half the sample
(400)
By whom: Trained interviewers
recruited participants
To whom: Half the sample
(400)
Outcome definitions
and method of
analysis
their intention to have
a screen for oral
cancer: “how likely
would you agree to
have a check-up of
your mouth for cancer
if one was offered by
your dentist?”
Outcome measure:
Questionnaire
response
Outcome measure
validated: Yes
Unit of measurement:
7 point scale from
‘extremely unlikely’ to
‘extremely likely’
Time points
measured: End of
intervention
Outcome name: 3)
Anxiety levels
Outcome definition:
Anxiety about having a
check for mouth
cancer
Outcome measure:
Questionnaire
response
Outcome measure
validated: Yes
Unit of measurement:
Results
Notes by review
team
ANOVA was not biased
(F[7,740]= 1.16, P>0.3).
Those who responded
in dental surgeries
indicated approximately
one extra correct
knowledge item
compared to
respondents in medical
surgeries. The effect of
reading the leaflet in
different dental or
medical settings was
insignificant (F[1,739]=
0.10, P>0.8).
Paper Two:
A limitation of the
study was the use of
single item rating
scales to assess the
anxiety, intention and
perceived risk
constructs. A more
sophisticated multiitem approach would
be preferable. Some
positive evidence of
the reliability of the
scales employed was
found, although the
undergraduate
students used, to gain
this supporting
information, would
tend to give reliability
estimates at their
upper bound.
Questionnaire results:
Intervention group(s):
Sign of mouth cancer: a
red patch in the mouth:
87.9%
More likely to get mouth
cancer if a man: 67.3%
Sign of mouth cancer: a
white patch in the
mouth: 85.3%
More likely to get mouth
cancer if drink alcohol
heavily: 72.3%
A check up for mouth
cancer is carried out
using x-rays: 82.7%
In the UK about 1000
people die a year of
mouth cancer: 82.8%
Paper Three:
Paper Two:
The limitations of
these studies bear
inspection. First, we
adopted self-report to
categorise the
patients’ smoking
status rather than
continue testing. This
later approach would
have raised the costs
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Population and
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Method of allocation to
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oral cancer in
primary care
attendees (Papers 1
and 2).
Education: NR
Socioeconomic
position: NR
Social capital: NR
How delivered: N/A
When/where: Dental practices
and medical practices
To investigate
whether primary
care patients who
claim to smoke
tobacco gain greater
benefit of a patient
information leaflet
on oral cancer than
non-smokers (Paper
Three).
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): Each
interviewer was
required to approach
50 patients. The
interviewers were
trained to ask for
consent and to note
all refusals. Gender
and age group was
determined to assess
for a possible
difference in
response to questions
(e.g. patients refusing
to enter study may
diminish
generalisation of the
findings as
displayed).
Randomisation into
leaflet (experimental)
and non- leaflet
(control) groups was
conducted by
designating whole
Study Design: RCT
Quality Score (++,
+, or -): +
External
Validity(++, +, or -):
+
How often: Once
How long for: One day
Sample size at baseline:
Total sample N = 800
Intervention group N = Half
the sample (400)
Control Group N = Half the
sample (400)
Baseline comparisons (report
any baseline differences
between groups in important
confounders): There were a
larger proportion of females in
the ‘no leaflet' control group.
Subsequent analyses controlled
for gender to remove the
possibility of this variable
confounding interpretation.
Study sufficiently powered
(power calculations and provide
details): At 80% power to detect
a mean difference of one
correct question assuming a
common SD of 4.5 when the
sample sizes in the 2 groups
are 220 and respectively, a total
sample size of 800 would be
required. However due to drop-
Outcome definitions
and method of
analysis
Five category rating
scale from ‘not
anxious’ to ‘extremely
anxious’
Time points
measured: End of
intervention
Outcome name: 4)
Perceived risk
Outcome definition:
Perceived risk of
mouth cancer in the
next year
Outcome measure:
Questionnaire
response
Outcome measure
validated: Yes
Unit of measurement:
Seven-point scale
ranging from
‘extremely unlikely’ to
‘extremely likely’
Time points
measured: End of
intervention
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
Results
Notes by review
team
More likely to get mouth
cancer if aged over 50
years old: 67.9%
Sign of mouth cancer: a
yellow patch in the
mouth: 81.9%
Sign of mouth cancer:
an ulcer that does not
heal: 94.8%
Sign of mouth cancer: a
painless ulcer: 74.9%
More likely to get mouth
cancer if smoke
tobacco: 81.7%
More likely to get mouth
cancer is chew
tobacco: 64.3%
More likely to get mouth
cancer is lost all teeth:
91.7%
of the study
considerably. Further,
as the correlation
between self-report
and continue testing is
very high particularly
when demand
characteristics of the
question are low
(anonymous
questionnaire), as in
this case, a second
limitation was that a
post-test only design
was employed.
Previous work,
however, by our group
suggests that the
advantage of a more
complex, pre-test
design, especially in a
primary care setting,
might be marginal.
Third, the external
validity of the findings,
that is generalisability,
should be treated with
some caution.
Randomisation was
conducted by session
rather than by
individual. In addition
both studies were
conducted in the North
West of the UK. Study
1 [the study reviewed
Control group(s)
Sign of mouth cancer: a
red patch in the mouth:
48.3%
More likely to get mouth
cancer if a man: 30.1%
Sign of mouth cancer: a
white patch in the
mouth: 50.1%
More likely to get mouth
cancer if drink alcohol
heavily: 38.9%
A check up for mouth
cancer is carried out
using x-rays: 49.9%
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
sessions to either
experimental or
control group.
outs only 739 responses were
received (Paper One only)
State if eligible
population is
considered by the
study authors as
representative of
the source
population: Wide
ranging set of
localities within the
area selected. The
mean deprivation
scores and standard
deviations of the
wards associated with
the practices
according to the
Townsend indices
were close to the
mean and standard
deviations for
Merseyside as a
whole.
Inclusion Criteria:
NR
Outcome definitions
and method of
analysis
made for any baseline
differences in
important
confounders):
ANOVA was used in
Paper Three to
examine the
interaction effects of
receiving/not receiving
a leaflet with
smoking/not smoking.
Other variables such
as gender were also
included. “Anxiety
levels” and “Intention
to have screen” were
analysed using the
Mann-Whitney U test.
Results
Notes by review
team
In the UK about 1000
people die a year of
mouth cancer: 50.1%
More likely to get mouth
cancer if aged over 50
years old: 38.9%
Sign of mouth cancer: a
yellow patch in the
mouth: 53.4%
Sign of mouth cancer:
an ulcer that does not
heal: 74.2%
Sign of mouth cancer: a
painless ulcer: 55.1%
More likely to get mouth
cancer if smoke
tobacco: 71.8%
More likely to get mouth
cancer is chew
tobacco: 56.5%
More likely to get mouth
cancer is lost all teeth:
88.1%
here] however
confirmed that the
variation of deprivation
level (as assessed by
the Townsend score)
was independent of
mean knowledge level
for the participating
patients at the range
of practices sampled.
Paper Three –
Subgroup breakdown
by smokers and nonsmokers:
Whole sessions were
allocated to either
group so
randomisation was
pseudo. Allocation
was not concealed
and there is no
information on
blinding.

Exclusion Criteria:
NR
% of selected
individuals agreed
to participate: 855
Intervention group:
People that
received the leaflet
and responded to
the questionnaire
(374): 276 nonsmokers and 98
Limitations identified
by review team:
50 patients were
approached in each
clinic but the paper
doesn't say why the 50
were selected. The
age level of refusers
was significantly
higher than the
participants.
Not all questions in the
questionnaire are
171
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
patients were
approached, of whom
55 refused. Reasons
for refusal included:
no spectacles for
reading (n=25); did
not have time (n=15);
not interested (n=8);
unable to read or
write (n=6); and too
much pain from
symptoms (n=1). The
response rate was
94%.
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results

smokers
Control group:
People that did not
receive the leaflet
and responded to
the questionnaire
(365): 263 nonsmokers and 102
smokers
Paper Three –
Subgroup ANOVA
results:

Potential sources of
bias:

There was a small
overall difference in
knowledge across
the smoking
classification,
regardless of leaflet
exposure [smokers
= 27.18, 95% CI:
26.59, 27.78;
nonsmokers=
27.95, 95% CI:
27.58, 28.31; F(1,
733)= 5.19,
p=0.023
The interaction of
smoking status with
experimental
condition was
significant
[F(1,733)= 4.65,
p=0.031]
Notes by review
team
outlined in the paper
or reported on.
There was no
information on how
drop-outs affected the
results (although less
than 20% dropped
out).
The questionnaire was
given directly after
reading the leaflet so
the follow-up time was
not meaningful.
Evidence gaps:
Paper One:
The present study can
only show the
immediate effects on
knowledge of oral
cancer and further
work is required to
determine any longerterm benefits.
Future studies in the
oral cancer field are
needed. There is a
need to focus on the
longer-term increase
in knowledge and
awareness of oral
cancer from written
172
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team

information supplied in
general practice. In
addition assessment is
required of the
benefits of using
leaflets with targeted
populations such as
smokers and those
from areas of high
deprivation. The
relationship between
increased knowledge,
anxiety concerning
oral cancer and
likelihood of patients
accepting an oral
health screen is not
understood and
explorative
investigation is
warranted.


Respondents not
shown the leaflet
who claimed to
smoke had lower
levels of knowledge
than nonsmokers
(mean= 24.17, 95%
CI: 23.33, 25.01;
and mean= 25.65,
95%CI: 25.12,
26.18, respectively)
Whereas similar
knowledge levels
were found in
smokers and
nonsmokers after
reading the leaflet
(mean= 30.19, 95%
CI: 29.35, 31.04;
and mean= 30.24,
95%CI: 29.74,
30.75 respectively).
Gender, type of
practice attended
(dental v medical)
and past smoking
history (never
smoke v smoked
previously) did not
explain extra
variance of oral
cancer knowledge
when fed into an
ANOVA model with
leaflet and the
Paper Two:
Further work is
required to understand
the relationship of
patient attitudes to
behavioural intentions
and actual behaviour.
In addition, patient
views about having a
screen need urgent
study to determine
whether there are
identifiable
psychological costs as
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
associated
interaction term
(p>0.05)
2) Intention to have a
screen for oral cancer
Whole sample:
Mean: 5.70
Standard Error: 0.06
Intervention group:
Mean: 5.89
Standard Error: 0.08
Control group:
Mean: 5.52
Standard Error: 0.09
Reported intervention
to have an oral cancer
screen was higher in
the information group
than the control group.
This was confirmed by
conducting the MannWhitney U test on the 7
category rating scale
(z=-3.67, P<0.001). To
support the above
analysis, it was found
that 79.3% of those
exposed to the leaflet
compared to 69.8%
who had not, reported
they were more likely
Notes by review
team
already. The data from
this present study
would support the
view that informing
patients in primary
care, by a leaflet about
oral cancer has, on
average, no adverse
effects.
Paper Three:
An issue that warrants
further investigation is
the extent that
introducing written
materials, similar to
the patient information
leaflet used in this
study, may influence
clinician behaviour.
Source of funding:
NR
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
(i.e. extremely likely or
quite likely categories)
to have a screen; 95%
confidence interval for
difference 4.0-15%).
In addition a
multivariate logistic
regression analysis was
conducted with
intention to have a
screen as a dependent
variable. Significant
predictors of intention
to agree to have a
screen were knowledge
of oral cancer and
anxiety about the
screen.
3) Anxiety levels
Whole sample:
Mean: 1.78
Standard Error: 0.04
Intervention group:
Mean: 1.71
Standard Error: 0.05
Control group:
Mean: 1.86
Standard Error: 0.06
Those participants
given information
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
reported reduced
anxiety (Mann-Whitney
U test: z=-2.07, P<0.05)
compared with controls.
A logistic regression
model was used to
make adjustments for
gender which found
that gender imbalances
were not responsible
for this difference.
4) Perceived risk
Whole sample:
Mean: 2.53
Standard Error: 0.05
Intervention group:
Mean: 2.49
Standard Error: 0.07
Control group:
Mean: 2.57
Standard Error: 0.08
Attrition details: Less
than 20% drop outs. 35
were from control group
while 26 were from the
intervention group. No
information about how
this affected results.
Conclusion:
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Paper One: Two
important issues were
highlighted by the
findings. First, the
influence of the leaflet
was independent of
setting as the
knowledge increase
was no greater in the
dental or medical
practices. Second, the
leaflet appeared to
achieve important gains
in knowledge about
signs and risk factors of
oral cancer. The leaflet
did not influence
knowledge
substantially, on some
items, and this
appeared to be
explained by a
moderate ceiling effect.
For example, 88% of
patients, without access
to the leaflet, were
already aware that the
loss of teeth was not a
risk factor.
Paper Two: Provision of
information about oral
cancer to patients
attending primary care
facilities appeared to
have no adverse effects
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
on likelihood to agree to
a screen or result in
increased anxiety.
Intention to agree to
have a screen was
predicted positively by
knowledge level of oral
cancer and negatively
by anxiety towards the
screen, controlling for
age, sex and practice
type. These results
support the involvement
of practitioners in
introducing an
educational element
into their contact with
patients. This would
improve the
acceptability of
opportunistic screening
for oral cancer.
Paper Three: Smokers
were reporting identical
knowledge levels to
their non-smoking
counterparts, but only
when having read the
leaflet. Without access
to the leaflet, patients
who smoked were not
as knowledgeable
about oral cancer.
178
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author: Humphris,
B. M, Freeman, R,
Clarke, H.M.M
Source
Population(s):
Country of study
(include if developed
or non-developed)
Patients attending
20 general dental
practices in Northern
Ireland were invited
to participate.
Twenty practices
were selected (36%
of all general dental
practitioners) within
the Southern Health
and Social Services
Board (SHSSB) in
Northern Ireland.
Method of allocation (describe
how selected individuals/clusters
were allocated to intervention or
control groups – state if not
reported): Patients were
randomised by whole sessions
Outcomes (include
details of all relevant
outcome measures
and whether
measures are
objective or subjective
or otherwise
validated):
For each outcome
report
Limitations identified
by author:
Means, SDs, pvalues, CIs, Effect
sizes, SEs
The level of
participation was high in
the study although of
those who refused there
was an
overrepresentation of
older people.
Year: 2004
Citation: Humprhis,
G.M., Freeman, R.,
and H.M.M. Clarke.
Risk perception of
oral cancer in
smokers attending
primary care: a
randomised
controlled trial. Oral
Oncology (2004); 40;
916-924
Country of study:
Northern Ireland
Aim of Study: To
test the effect of a
disease specific
Patient Information
Leaflet (PIL) on the
oral cancer risk
perceptions and
knowledge of oral
cancer of patients
attending their
dentist for routine
care.
Study Design:
Setting:
Southern Health and
Social Services
Board, Northern
Ireland.
The mean Noble
deprivation index,
based upon the
postcode of the
practice, was 19.9
for participating
dentists which
compares closely to
the average (20.14)
for the SHSSB area.
Report how confounding
factors were minimised: No
statistically significant baseline
differences were reported.
Contamination was minimised as
patients were allocated by timed
sessions.
Programme/Intervention
description:
What was delivered: PIL was
given to be read and then
collected and a questionnaire
given to complete. Four questions
on socio-demographic
characteristics were included in
the questionnaire. Scales to
assess knowledge of oral cancer,
and perception of risk were
included
Theoretical basis: NR
By whom: Trained Interviewers
To whom: Participants
How delivered: PIL was given
including factual information on
the signs and symptoms of oral
cancer, risk factors, prevalence
Outcome name:
Knowledge of oral
cancer
Outcome definition:
Knowledge of oral
cancer
Outcome measure:
questionnaire
Outcome measure
validated: Yes
Unit of
measurement:
percentage of correct
responses
Time points
measured: End of
intervention
Outcome name: Risk
perception
Outcome definition:
Perceived risk of
mouth cancer
Outcome measure:
Oral health (clinical)
results:
Behavioural results:
Knowledge of oral
cancer
Intervention group:
Mean: 28.51
95% CI: 28.15, 28.87
Control group:
Mean: 26.49
95% CI: 26.14, 26.84;
All respondents who
received the PIL
reported greater
knowledge than
those who did not
receive the PIL
F[1,932]= 62.43,
p<0.001
NOTE: additional
information
comparing
Self-reports of tobacco
smoking have a
tendency to under
report.
There are numerous
approaches to estimate
risk and for a more
comprehensive
understanding of the
place that smoking can
influence perception of
risk no single method
should be preferred.
Limitations identified
by review team:
Only difference between
refusers and
responders was a slight
difference in age.
Allocation to condition
179
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Parallel
A randomised
control design was
employed.
Patients were
randomised by
whole sessions so
that all attendees in
a single session
(defined as the
typical period when
the practice was
open for a series of
patients) were
allocated to either
the PIL or no PIL
condition. This
feature of the design
was deliberate to
avoid ‘contamination’
within a session
when individuals
were randomised.
Quality Score (++,
+, or -):
+
External
Validity(++, +, or -):
++
Population and
setting
Location (urban or
rural):
NR
Sample
characteristics: NR
Age: Mean (SD) age
42 years (of the
944). Range 18-86
Sex: Male 332,
female 612 (out of
the 944 completers)
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education Completed full time
education: ≤ 16
years: Intervention=
196 (45%); Control=
203 (47%); 17-18
years: Intervention=
138 (32%); Control=
140 (32%); ≥ 19
years: Intervention=
93 (23%) Control=
93 (21%)
Socioeconomic
position: NR
Social capital: NR
Method of allocation to
intervention/control
and mortality rates and
behaviours to reduce risk and
promote early detection. A
questionnaire was then
administered.
When/where: General dental
practices
How often: Once
How long for: One day
Control/Comparator
description:
What was delivered:
Questionnaire
By whom: Trained Interviewers
To whom: Participants
How delivered: A questionnaire
was administered.
When/where: General dental
practices
How often: Once
How long for: One day
Sample size at baseline: NR
Total sample N = 967 (complete
data was received from 944
participants)
Intervention group N = 480 (13
uncompleted) = 467 completed
replies.
Control Group N = 487 (10
uncompleted) = 477 completed
replies
Baseline comparisons (report
Outcome definitions
and method of
analysis
questionnaire
Outcome measure
validated: Unclear
Unit of
measurement:
percentage of correct
responses
Time points
measured: End of
intervention
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders): ANOVA
was used to analyse
the results for
knowledge of oral
cancer. Chi-square
statistics were
adopted to analyse
the risk perception
outcome. Multiple
logistic regression
was used to predict a
higher risk perception,
with smoking
behaviour, receipt of
the leaflet, smokes
Results
Notes by review team
intervention and
control scores for
different questions is
contained in the Data
Extraction form.
was completed by
randomisation by whole
session.
There was no overall
difference in
knowledge scores
across the smoking
classification
regardless of whether
respondents had
read the PIL or not
(F[2.932] = 2.39,
p=0.092). the
interaction of
smoking status with
experimental
condition was
significant (F[1,932]=
3.02, p= 0.049).
The median percent
improvement due to
the PIL was 4 (min,
max:) 13, 36;
IQR=9.8). In 2
previous studies with
the ‘Mouth Cancer:
are you at risk?’ PIL
produced by ZilaTM
Europe the
equivalent median
values were 10 (min,
max: 3, 40;
Not all items from the
questionnaire were
included.
It was not recorded
whether the person(s)
determining allocation
to condition could have
influenced this process.
It was not recorded
whether the participants
and investigators were
blind to the aims and
outcomes of the
research.
It was not recorded
whether the exposure to
the intervention or
control group was
adequate.
Attrition rates were less
than 20%.
The intervention only
partially reflected the
usual UK practice as it
was administered by
trained interviewers.
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Study details
Population and
setting
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area): Patients
were randomised by
whole sessions
State if eligible
population is
considered by the
study authors as
representative of
the source
population:
Mean Noble
deprivation index of
the sample
compares closely
with the average of
the area
Inclusion Criteria:
Subjects aged 16
years or above,
having given written
consent and English
language spoken.
Exclusion Criteria:
Visitors to the
practice or relatives
Method of allocation to
intervention/control
any baseline differences between
groups in important confounders):
The randomisation procedure
successfully achieved
equivalence between
experimental and control groups,
as age, gender, self-reported
behaviour (dental attendance,
tobacco and alcohol use), and
previous quit attempts were found
not to be statistically different
between groups (all p>0.05).
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of
analysis
and previous smoking
behaviour as
independent
variables. Use of ITT
was not mentioned.
Results
Notes by review team
IQR=15.2) and 14
(min, max: 0, 35;
IQR=14.8)
respectively.
Not all of the outcome
measures were reliable.
Risk perception –
perceived risk of oral
cancer
Of the 467 patients
with access to the
PIL, 49 perceived
their risk of mouth
cancer as higher than
others (11%),
whereas 33 of the
477 control patients
(7%) held this view.
The effect of the PIL
on perceptions of risk
was marginally
2
significant (x = 3:80,
df1, p = 0:051)
regardless of
smoking level. There
was an enhancement
of risk perception in
smokers, as 34%
(37/110) who had
read the PIL believed
they were at risk
compared to 22%
(23/106) of the
2
controls (x = 3:84,
df1, p = 0:05). The
effects of the PIL on
Not all questionnaire
results were reported.
Not all outcomes were
accessed only the
knowledge and
attitudes.
Follow-up in the form of
a questionnaire was
given directly after the
leaflet.
Intervention group and
control group were not
similar at baseline.
ITT was not recorded.
The estimates of effect
size were shown
sometimes with a p
value.
It was not reported
whether the analytical
methods were
appropriate.
Some p values were
given when considering
the precision of the
intervention effects that
181
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
of patients were
excluded.
% of selected
individuals agreed
to participate:
28 refusals
(response rate
97%): lack of
interest (8),
insufficient time (8),
non-possession of
glasses (4) other (8)
23 uncompleted
after randomisation.
Potential sources
of bias: NR
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
those who used to
smoke and had never
smoked was not
significant statistically
2
(x = 1:04, df1, p =
2
0:31 and x = 1:79,
df1, p ¼ 0:18
respectively). These
results are presented
in Fig. 1 – p.920
were given.
Multiple logistic
regression was
performed with risk
as the dependent
variable. Risk was
dichotomised into
those who perceived
themselves at greater
risk (coded 1) against
those who believed
they were at the
same or less risk
(coded 0). 4 factors
were introduced into
the model, 3 as
categorical predictors
including PIL access
(or not), smoking
behaviour (3 levels:
smoker, past smoker
and never smoked)
and sex. Age was
entered as a
continuous variable.
The 2 demographic
The data from this study
has only partial internal
validity.
Evidence gaps:
To design more
effective
communications, to
demonstrate that the
increase in personal
vulnerability that
smokers expose
themselves, will
depend, in part, on
researchers developing
good systems of
measurement of risk
perception.
Source of funding: NR
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
variables (age and
sex) were found not
to contribute to risk
perception and hence
were omitted ðp >
0:05Þ. The 2
remaining variables:
PIL access and
smoking behaviour
each had an
independent effect on
risk perception
adjusted for the other
ðp < 0:05Þ. The
smokers were 16
(95% CI: 8–30) times
more likely to
perceive they were at
greater risk of oral
cancer than the
nonsmokers
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control): 28 refusals
(response rate 97%):
lack of interest (8),
insufficient time (8),
non-possession of
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
glasses (4) other (8)
23 uncompleted after
randomisation.
Conclusion: This
study extends
previous work to
show that first,
minimal interventions
such as PILs can be
effective in raising
awareness about
signs and symptoms
of oral cancer in
patients attending
their dentist and this
effect is linked to
smoking behaviour.
Secondly,
perceptions of risk
are closely
associated with
current self-reported
tobacco smoking.
Finally, a PIL may
marginally increase
risk perception of oral
cancer and this may
be partially
dependent on
smoking status.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Humphris,
G.M. and E.A. Field
Source
Population(s):
Practices were
selected from areas
of the north west of
England that were
situated in a wide
ranging set of
localities.
Method of allocation
(Describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): Pseudo
randomisation - whole
sessions were allocated to
either group.
Outcomes (include
details of all relevant
outcome measures
and whether
measures are
objective or
subjective or
otherwise validated):
1) Knowledge of oral cancer
Limitations
identified by author:
Setting: 16 practices
(9 dental, 7 medical)
within Merseyside
from a wide ranging
set of localities.
Deprivation has
been highlighted as
a key variable in
predicting various
aspects of oral
health11,12 and is
often expressed as a
summary measure
known as the
Townsend index.13
Report how confounding
factors were minimised:
Baseline imbalances were
inspected and found not to be
significant with the exception
of gender. Gender was
controlled for in the analysis.
Allocation was not concealed
but contamination should have
been minimal as groups rather
than individuals were
randomised.
Outcome name: 1)
Knowledge of oral
cancer
Outcome definition:
Knowledge level
Outcome measure:
Responses to 36
attitude statements
(self-reporting by
patient)
Outcome measure
validated: Unclear
Intervention – leaflet group:
Mean: 30.87
Standard error: 0.18
95% CI: 30.51-31.24
Unit of
measurement: Yes /
no or true / false
answers
The most significant effect of
reading the leaflet was upon
knowledge level (t = 17.85,
df = 767, P < 0.001). Almost
five extra question items
(mean = 4.77, 95%CI =
4.24, 5.29) were correctly
answered, on average, after
access to the leaflet.
Year: 2003 (Paper
One) 2004 (Paper
Two)
Citation:
Humphris, G.M.
and E.A. Field, The
immediate effect on
knowledge,
attitudes and
intentions in
primary care
attenders of a
patient information
leaflet: a
randomised control
trial replication and
extension. British
Dental Journal,
2003. 194(12): p.
683-8; discussion
675 (Paper One).
Humphris, G.M.
and E.A. Field, An
oral cancer
information leaflet
for smokers in
primary care:
results from 2
Location (urban or
rural): NR
Sample
characteristics:
Age: Mean age for
leaflet group = 42.63
Mean age for no
Programme/Intervention
description: Leaflet group
What was delivered: After
obtaining consent, the patients
in the experimental group were
given the leaflet to read and
return to the researcher. All
participants completed the
questionnaire:
Theoretical basis: N/A
By whom: Interviewers recruit
Time points
measured: End of
intervention
Outcome name: 2)
Attitudes about
negative
consequences
Detailed results for the top
10 of 36 statements are
contained in Table 4 of
Paper 1 and in an outcome
table in the data extraction
form
Control – no leaflet group:
Mean: 26.11
Standard error: 0.19
95% CI: 25.73-26.48
P Level: 0.001
Effect size: 1.29
Paper Three – results for
Outcome 1) by smokers and
non-smokers:
Paper One:
Some limitations of
the study are noted.
Participation rate was
high although dropout analysis indicated
older members of the
practice refused. In
addition, some
patients who
consented did not
complete the full
questionnaire.
However, the extent
of the loss was
similar across the
experimental and
control groups
thereby reducing the
possibility of bias.
Caution should be
employed when
generalising more
widely beyond the
North West of
England, although
there was no
association of
practice (and
indirectly deprivation)
with knowledge level.
It is worth noting that
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Study details
Population and
setting
Method of allocation to
intervention/control
randomised
controlled trials.
Community
Dentistry and Oral
Epidemiology,
2004. 32(2): p. 1439. (Paper Two)
[NOTE: This paper
also reports results
from a separate
study – these are
dealt with in a
separate evidence
table - Humphris et
al 2001]
leaflet group = 42.76
Sex: Leaflet group =
55.6% female,
44.4% male
No leaflet group =
62.1% female,
37.9% male
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
participants. Leaflet gives
message - produced by Zila
Europe
To whom: 428 patients
How delivered: The leaflet
contained pictorial, diagnostic
and textual information,
presented under headings
designed in a question and
answer format on a multicoloured, double-sided, glossy
A4 sheet, folded to provide 6
sections. The leaflet scores
highly (11 out of a possible
maximum of 13) on the new
evaluation system for patient
information sheets (MIDAS).
When/where: Dental or
medical practice – waiting
room
How often: Once –
questionnaire immediately
followed leaflet administration
How long for: One day
Country of study:
England
Aim of Study:
Paper One:
To determine
whether the
influence of a
leaflet on mouth
cancer
improves
knowledge, related
attitudes and
intention to accept
a mouth screen.
Paper Two:
To investigate
whether primary
care patients who
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area): Trained
interviewers arrived
at the practices on
days where nonspecialist, that is
routine services,
were provided.
Session allocation
was previously
Control/Comparator
description: No leaflet group
What was delivered: All
participants completed the
questionnaire:
By whom: Interviewers recruit
participants.
To whom: 433 patients
How delivered: N/A
When/where: Dental or
Outcome definitions
and method of
analysis
Outcome definition:
Attitudes about
negative
consequences
Outcome measure:
Responses to 2
attitude statements five point Likert scale
– from ‘strongly
agree’ to ‘strongly
disagree’ (selfreporting by patient)
Outcome measure
validated: Unclear
Unit of
measurement: Likert
score
Time points
measured: End of
intervention
Outcome name: 3)
Attitudes about lack
of control
Outcome definition:
Attitudes about lack
of control
Outcome measure:
Responses to 2
attitude statements five point Likert scale
– from ‘strongly
agree’ to ‘strongly
disagree’ (self-
Results

There was a small
overall difference in
knowledge across the
smoking classification
regardless of whether
respondents had read
the leaflet [smokers=
28.01, 95%CI: 27.52,
28.49; non-smokers=
28.61, 95% CI: 28.30,
28.92; F(1, 778);=4.17,
p<0.0048.
 The interaction of
smoking status with
experimental
condition was
significant (F[1,
778]= 10.32,
p<0.001
 Amongst
respondents without
access to the leaflet
(control group) it
was found that
smokers had lower
levels of knowledge
than nonsmokers
(mean=25.06,
95%CI: 24.35,
25.77; and mean=
26.54, 95%CI:
26.08, 27.01,
respectively).
 Respondents who
Notes by review
team
the study describes
only the immediate
effect of the leaflet
and further work has
started to shed light
on the longer term
effects.
Paper Two:
The limitations of
these studies bear
inspection. First, we
adopted self-report to
categorise the
patients’ smoking
status rather than
continue testing. This
later approach would
have raised the costs
of the study
considerably. Further,
as the correlation
between self-report
and continue testing
is very high
particularly when
demand
characteristics of the
question are low
(anonymous
questionnaire), as in
this case, a second
limitation was that a
post-test only design
was employed.
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Study details
Population and
setting
Method of allocation to
intervention/control
claim to smoke
tobacco gain
greater benefit of a
patient information
leaflet on oral
cancer than nonsmokers.
recorded from
random number
computer generated
assignment.
Instructions included
advice to continue
practice visits until
25 patients from
each study condition
had been
successfully
collected. Surplus
participants (i.e. > 25
per condition) were
included.
medical practice – waiting
room
How often: Once
How long for: One day
Study Design:
Parallel RCT
Quality Score (++,
+, or -): +
External
Validity(++, +, or ): +
State if eligible
population is
considered by the
study authors as
representative of
the source
population: The
Townsend indices
associated with the
locality from which
the practice resided
at ward level were
comparable (mean =
4.35; SD = 4.73) to
the values for
Merseyside (mean =
3.68; SD = 4.56).
Waiting rooms.
Sample size at baseline:
Total sample N = 861
Intervention group N = 428
Control Group N = 433
Baseline comparisons (report
any baseline differences
between groups in important
confounders): Slightly higher
percentage of females in the
no leaflet group (62.1%)
compared to leaflet group
(55.6%). The randomisation
procedure successfully
achieved equivalence between
experimental and control
groups, as age, gender and
setting of the waiting room
(dental or medical) were found
not to be statistically different
between groups (all p
values>0.05).
Study sufficiently powered
(power calculations and
provide details): NR
Outcome definitions
and method of
analysis
reporting by patient)
Outcome measure
validated: Unclear
Results
Unit of
measurement: Likert
score
Time points
measured: End of
intervention

Outcome name: 4)
Normative beliefs
Outcome definition:
The assessment of
beliefs about whether
other people would
sanction the
respondent to accept
a mouth cancer
screen.
Outcome measure:
Tapped using 3 pairs
of items which each
consisted of 2
statements. A
strongly agree/
strongly disagree 5
point likert scale was
used for each item of
the pair. Both items in
the pair were
multiplied to derive a
product ranging from
1 to 25. All 3 pairs

Notes by review
team
had read the leaflet
had similar levels of
knowledge
regardless of
smoking status
(smplers:
mean=31.07, 95%
CI: 30.40, 31.73;
nonsmokers:
mean=30.72, 95%
CI: 30.29, 31.15)
ANOVAs were also
undertaken to check
the effects of selfreported regularity
of dental attendance
and alcohol
consumption
(controlling for age)
which found no
significant effects.
Additional
information on
specific items of
knowledge is
available in the data
extraction form.
2) Attitudes about negative
consequences
Intervention – leaflet group:
Mean: 3.73
Standard error: 0.08
95% CI: 3.57-3.88
Previous work,
however, by our
group suggests that
the advantage of a
more comples, pretest design,
especially in a
primary care setting,
might be marginal.
Third, the external
validity of the
findings, that is
generalisability,
should be treated
with some caution.
Randomisation was
conducted by session
rather than by
individual. In addition
both studies were
conducted in the
North West of the
UK. Study 1 [the
study reviewed with
Hugoson et al 2001]
however confirmed
that the variation of
deprivation level was
independent of mean
knowledge level for
the participating
patients at the range
of practices sampled.
Limitations
identified by review
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Inclusion Criteria:
Inclusion criteria
were to invite all
consecutively
attending patients
who spoke English,
and were 16 years of
age or above.
Exclusion Criteria:
Visitors to the
practice or relatives
of patients were
excluded.
% of selected
individuals agreed
to participate: A
total of 949 patients
were approached, of
whom 88 refused, so
approximately 91%
accepted. The
refusers were of
similar gender
composition to the
respondents (χ² =
1.65; df = 1; P = 0.2).
Age level of refusers
was higher than
respondents (χ² =
39.97; df = 5; P <
0.001).
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
were summed to
produce a scale
ranging from 3 to 75.
Outcome measure
validated: Unclear
Results
Unit of
measurement: Likert
score
P Level: 0.038
Effect size: 0.15
Time points
measured: End of
intervention
Outcome name: 5)
Anxiety about
screening procedure
Outcome definition:
Anxiety about having
a mouth screen.
Outcome measure:
Comprised 3 items
which were summed
to give a scale
ranging from 3 to 15
(low to high anxiety).
Outcome measure
validated: Unclear
Unit of
measurement: Score
on a 5 point rating
scale
Time points
measured: End of
Notes by review
team
team:
Control – no leaflet group:
Mean: 3.97
Standard error: 0.08
95% CI: 3.81-4.13
Paper Two t-test results for
the impact of the leaflet on
smokers and non-smokers:
Will give discomfort (reverse
scored):
 Non-smokers: effect
size=0.11; 95% CI=0.06-0.28; p=0.204
 Smokers: effect
size=0.11; 95% CI=0.17-0.39; p=0.439
A waste of time (reverse
scored):
 Non-smokers: effect
size=0.01; 95% CI=0.16-0.18; p=0.939
 Smokers: effect
size=0.03; 95% CI=0.25-0.31; p=0.816
3) Attitudes about lack of
control
Intervention – leaflet group:
Mean: 7.67
Standard error: 0.09
Only pseudorandomisation was
used (whole sessions
were allocated to
each group).
Not all questions in
the questionnaire
were included in the
report (however - this
was partly because
they were grouped
under different
outcomes).
There was no
information on
whether the
allocation was
concealed and
whether blinding was
used.
The figures for dropout rates in the 2
papers are different
and there is no
explanation for this.
The questionnaire
was given directly
after the leaflet so the
follow-up time was
not meaningful.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Potential sources
of bias:
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
intervention
Results
Outcome name: 6)
Intention to accept
screen
Outcome definition:
Intention to accept
screen
Outcome measure:
Assessed with 2
questions. A 7 point
scale was applied to
both questions.
Outcome measure
validated: Unclear
Control – no leaflet group:
Mean: 7.91
Standard error: 0.09
95% CI: 7.72-8.10
Notes by review
team
95% CI: 7.49-7.86
Evidence gaps:
Unit of
measurement: Score
on 7 point scale
Time points
measured: End of
intervention
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any
baseline differences
in important
confounders):
Outcome 1
(knowledge of oral
cancer) was
P Level: 0.078
Effect size: 0.13
Paper Two t-test results for
the impact of the leaflet on
smokers and non-smokers:
Easy to ask for Mouth
Cancer Check if I wanted to
have:
 Non-smokers: effect
size=0.12; 95% CI=0.05-0.29; p=0.155
 Smokers: effect
size=0.14; 95% CI=0.14-0.42; p=0.325
Able to decide to allow
dentist to give Mouth Cancer
Check:
 Non-smokers: effect
size=0.05; 95% CI=0.12-0.22; p=0.544
 Smokers: effect
size=0.19; 95% CI=0.08-0.47; p=0.168
Paper One:
Questions remain
unanswered
however, including:
what is the duration
of the effect of this
written information,
and what implications
does the
improvement have on
patient and dentist
behaviour?
Paper Two:
An issue that
warrants further
investigation is the
extent that
introducing written
materials, similar to
the patient
information leaflet
used in this study,
may influence
clinician behaviour.
Source of funding:
NR
4) Normative beliefs
Intervention – leaflet group:
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
assessed using chisquared. All other
outcomes were
assessed using ttests.
Results
Notes by review
team
Mean: 12.51
Standard error: 0.24
95% CI: 12.03-12.99
Control – no leaflet group:
Mean: 13.34
Standard error: 0.25
95% CI: 12.84-13.83
P Level: 0.019
Effect size: 0.17
Mouth Cancer Check gives
early diagnosis of mouth
cancer:
 Non-smokers: effect
size=0.10; 95% CI=0.07-0.27; p=0.266
 Smokers: effect
size=0.04; 95% CI=0.24-0.32; p=0.778
Will reassure me:
 Non-smokers: effect
size=0.04; 95% CI=0.13-0.21; p=0.619
 Smokers: effect
size=0.30; 95%
CI=0.02-0.58;
p=0.032
5) Anxiety about screening
procedure
Intervention – leaflet group:
Mean: 5.23
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Standard error: 0.13
95% CI: 4.97-5.50
Control – no leaflet group:
Mean: 5.58
Standard error: 0.13
95% CI: 5.31-5.85
P Level: 0.069
Effect size: 0.13
Affective response to Mouth
Cancer Check - Anxiety:
 Non-smokers: effect
size=0.06; 95% CI=0.11-0.23; p=0.480
 Smokers: effect
size=0.11; 95% CI=0.17-0.39; p=0.428
Affective response to Mouth
Cancer Check - Worry:
 Non-smokers: effect
size=0.05; 95% CI=0.12-0.22; p=0.552
 Smokers: effect
size=0.24; 95% CI=0.04-0.52; p=0.087
Affective response to Mouth
Cancer Check - Concern:
 Non-smokers: effect
size=0.02; 95% CI=0.15-0.19; p=0.812
 Smokers: effect
size=0.32; 95%
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
CI=0.04-0.60;
p=0.24
6) Intention to accept screen
Intervention – leaflet group:
Mean: 12.15
Standard error: 0.12
95% CI: 11.91-12.39
Control – no leaflet group:
Mean: 11.61
Standard error: 0.12
95% CI: 11.36-11.86
P Level: 0.003
Effect size: 0.22
Intention to accept a screen
was more positive in
patients who had read the
leaflet (t = 3.02, df = 759, P
= 0.003). The strength of the
effect was low (mean
difference = 0.43, 95%CI =
0.10, 0.78, d = 0.22).
Bonferroni adjustment
indicated with 6 tests that
the significance level should
be altered to 0.008.
Paper Two t-test results for
the impact of the leaflet on
smokers and non-smokers:
Intention to have a Mouth
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Cancer Check:
 Non-smokers: effect
size=0.21; 95%
CI=0.04-0.38;
p=0.017
 Smokers: effect
size=0.21; 95% CI=0.06-0.49; p=0.126
Attrition details:
Indicate the number lost to
follow up and whether the
proportion lost to follow-up
differed by group (i.e.
intervention vs control)
53 incomplete
questionnaires from the no
leaflet group
39 incomplete
questionnaires from the
leaflet group.
Data with full information
was analysed leaving 769
respondents. The number of
dropouts due to missing
data was independent of
group assignment (χ² = 2.57,
P = 0.13).
Conclusion:
Paper One:
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
The findings from this study
confirm previous reports in 2
respects. First, the
improvement in knowledge
from access to the leaflet
was about the same in the
current and previous survey
(see Humphris 2001 x3
papers).
The intention of patients to
accept an oral cancer
screen was increased with
access to the leaflet. The
leaflet did appear to have an
influence on the beliefs of
patients about the difficulties
associated with having an
oral cancer check.
However anxiety about the
screening procedure was
not influenced by the leaflet
exposure unlike in the
original study (see Humphris
x2 2001).
This study supports previous
work by the authors in
confirming the strength of
effect of a well-designed
information leaflet. The main
influence was to increase
knowledge about signs and
associated risks of oral
cancer.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Paper Two:
As predicted the smokers
with access to the leaflet
were significantly more
reassured and less anxious
about having an oral health
screen. The effect on
behavioural intentions was
in a positive direction
consistent with prediction
but statistically
nonsignificant. Non-smokers
in comparison showed
statistically significant
enhanced intentions but not
other advantage with leaflet
exposure.
Smokers were reporting
identical knowledge levels to
their non-smoking
counterparts, but only when
having read the leaflet.
Without access to the leaflet,
patients who smoked were
not as knowledgeable about
oral cancer.
195
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: Jensen, O
et al
Study design: Qualitative
approach using focus group
interviews.
Population the sample
was recruited from: Oral
Health Professionals
(OHPs) from two Swedish
regions.
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Year: 2014
Citation: Jensen,
O., et al., 'I take for
granted that
patients know' - oral
health
professionals'
strategies,
considerations and
methods when
teaching patients
how to use fluoride
toothpaste.
International
Journal Of Dental
Hygiene, 2014.
12(2): p. 81-88.
Country of study:
Sweden
Quality Score (++,
+, or -): ++
Research aims, objectives,
and questions:
The aim of this study was to
explore the oral health
professionals’ (OHPs’)
perspectives regarding their
strategies, considerations and
methods when teaching their
patients the most effective way
of tooth brushing with fluoride
(F) toothpaste (abstract).
Theoretical approach
[grounded theory, IPA etc]:
State how data were
collected:
What method(s): Data were
collected through five focus
group interviews. Each group
consisted of at most 6 OHPs
with different educational
backgrounds, gender and
number of years in profession.
The first focus group included
OHPs working with an oral
health promotion programme in
schools. The second and third
groups represented OHPs
working in a Public Dental
Service in the Gothenburg
Region and the county of
How sample was
recruited: The participants
were selected through
purposive sampling,
meaning that the selection
is based on knowledge of
the population and the
purpose of the study. Thus,
in order to establish
credibility, OHPs of different
gender, professions and
professional backgrounds
were chosen. (p.82, pa.6)
How many participants
recruited: 23
Sample characteristics:
Age: NR
Sex: 18 women and five
men
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Sweden
Occupation: 10 dental
nurses, four dental
hygienists and nine
The analysis of the interviews was
based on qualitative content analysis. 2
of the authors (PG, OJ) made the first
analysis of the transcribed interviews,
and all the authors contributed at a
later stage to the analysis of the texts.
The analysis began with the authors
reading the interviews thoroughly
several times until they were familiar
with the texts. Statements about
knowledge, attitudes and behaviour
were marked in the text. The
statements were compared to find both
similarities and differences. The data
were systematically condensed and
coded to the relevant phrases that
identified their content. The following
steps were performed in the analytical
process:
1 Meaning units were identified, that is,
statements relating to the same central
meaning.
2 Abstractions were made, that is,
interpretation at a higher level of logic.
3 Codes were created, that is, meaning
units labelled.
4 Codes were sorted into
subcategories and categories, that is, a
group of content sharing a
commonality.
3 of the researchers (PG, OJ, LP)
A disadvantage of group
interviews is the possibility
that individual experience
will not be fully explored.
(p.86, pa.5)
Limitations identified by
review team:
Paper does not state
whether role of researcher
was described to
participants.
Only one method used
(focus group interviews) –
in focus groups not always
possible to gain individual
opinions in full/have a
representation of all the
views of those in
attendance.
Evidence gaps and/or
recommendations for
future research:
NR
Source of funding:
The study was financially
supported by the Public
Dental Service of the
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Uppsala, respectively, treating
patients from different socioeconomic areas. The fourth
group represented OHPs
working in a private dental
clinic in the county of Uppsala,
and the fifth group represented
dentists working as heads of
Public Dental Services in the
county of Uppsala (p.82,
para.6)
An interview guide was used
with questions about
background data on the
informants’ professions and
number of years in the
profession. Open-ended
questions were used to collect
data concerning the informants’
strategies when teaching
patients how to brush their
teeth and how to use F
toothpaste, for example, Can
you tell me about your
recommendations and
instructions about use of
fluoride toothpaste to the
patients? Follow-up questions
were asked when necessary.
The intention was to explore
the OHPs’ knowledge of and
attitudes about caries
prevention and what they said
to their patients concerning to
use the best ‘toothpaste
Population and Sample
Selection
dentists. (p.82, para.6).
Education: NR
Socioeconomic position:
NR
Social capital: NR
Inclusion criteria: NR
Outcomes and Methods of Analysis
Notes by Review Team
discussed the tentative subcategories
and categories, and the division was
revised until a consensus could be
achieved. Both the manifest and the
latent areas were grounded in the data
by selection of exploratory text
quotations.
(p.83, para.3)
Vastra Gotaland Region,
Sweden. (p.87, para.6)
Exclusion criteria: NR
Key themes and findings relevant to
this review [with illustrative quotes
if available]
(p.83-86)
3 categories were identified in the
manifest and latent analysis: (i)
strategies and intentions, (ii) providing
oral hygiene information and instruction
and (iii) barriers to optimal oral health
teaching. Each category consisted of 2
subcategories
Strategies and intentions:
Promoting oral health for the best
interest of the patient:
- For several participants, priority
was given to instructing patients
with oral diseases. However,
others felt that all patients need
advice on oral health.
- Patients own responsibility for
good oral health habits was
stressed.
- Participants highlighted that they
listen to the patient’s attitude to
earn their confidence and learn
about their abilities.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
technique’. Discussion focus
was on the informants’ own
descriptions of teaching and
their thoughts, feelings and
actions concerning the subject.
With the aim of stimulating the
discussion, the moderator
referred to findings from a
previous study where patients
had been interviewed about
what they knew about
toothbrushing’ and toothpaste.
3 quotations, ‘vignettes’, were
presented to the focus groups,
each representing statements
made by dental patients in the
abovementioned study.
Vignettes can be a useful way
to more clearly identify the
phenomena to be discussed.
The vignettes were as follows:
(i) ‘The dental care services
don’t teach you how to use
toothpaste…you put it on and
you brush’, (ii) ‘Some people do
say you aren’t supposed to
rinse… But I don’t know
whether that’s a good idea…
no dentist has ever told me not
to rinse it off…’ and (iii) ‘…but
you have no idea which
toothpaste really works. … You
can only find out from a
(company and brands) neutral
dentist …you don’t listen to the
message if there is a company
logo on it’.
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
-
Keen to give both positive and
negative feedback and not blame
the patient: “ …I guess I try to find
a way that’s easy for the patient
too, because you mustn’t make it
too complicated”
Working for one’s own sake:
- Some OHP’s expressed a need to
succeed for their own’ sake (as
well as the patient).
- Experienced satisfaction when
patients improved their oral health
Providing oral hygiene information and
instruction:
Advice on oral hygiene:
- Focussed more on toothbrushing
techniques rather than toothpaste.
- Advice to brush twice a day for 2
mins (although for some 2 mins
was too short)
- Some mentioned toothpaste
technique and/or fluoride
concentration as part of their
advice.
- Some informed patients (more so
children) about not rinsing after
brushing
- Some recommended toothpaste
brands (particularly if patient had
specific problems such as sensitive
teeth) but it was considered even
more important not to favour any
specific company
- The informants were of the opinion
that patients of all ages were
affected by advertisements, as
198
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
The interviews were digitally
recorded and later transcribed
verbatim by a professional
secretary and one of the
authors.
The interviews were performed
and transcribed in Swedish.
A professional translator
translated the quotations into
English. (p.82, para.7…)
By whom: The interviews were
performed by a moderator
(author, dentist) and an
observer (author, dental
hygienist). (p.82, para.7)
What setting: The interviews
took place at dental clinics or
conference centres in
Gothenburg and Uppsala.
(p.82, para.7)
When: NR
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
were the OHPs themselves.
Methods used for instruction:
- 4 aspects, knowledge, guidelines,
aids and time, were seen as
essential in terms of giving advice
on brushing and F toothpaste.
- The OHPs expressed uncertainty
and showed lack of knowledge
about the most effective F
toothpaste technique, saying that
they handled this issue
unsystematically. Some informants
also expressed dissatisfaction with
the changes of recommendations
over time indicating that this
created uncertainty.
- The informants discussed the issue
of time as a prerequisite for giving
oral hygiene advice. Their opinion
was that dental nurses had the
most time available for preventive
care and dentists the least time.
- It was also stated that dental
nurses give the highest quality
information and instructions.
Barriers to optimal oral healthcare
education:
Obstacles related to the patients:
- Opinion was that patient’s social
status not least the patient’s level
of education, could both facilitate
and present an obstacle to
providing optimal information.
- Some mentioned difficulties in
giving instruction to elderly patients
or patients from different cultural
199
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
backgrounds.
Obstacles related to the oral health
professionals:
- If the patient has been attending
the same clinic or being treated by
the same OH Professional for
many years, then it felt hard to tell
the patient that his or her oral
hygiene was inadequate and
improvements needed.
- Teenagers were described as
more careless with their oral
hygiene, and older men were
stated to be difficult to motivate to
change their habits.
- Some informants had even doubts
about the advantages of F
toothpaste because using
toothpastes without abrasives to
avoid tooth wear was more
frequently given advice than using
a large amount of toothpaste for
adding F to the oral cavity. Doubt
was also expressed about whether
F is a safe product or if it causes
fluorosis on the teeth of young
children. In addition, the informants
seemed to be embarrassed to talk
about something as self-evident as
toothpaste.
Conclusions:
In conclusion, the OHPs seemed to be
driven by good intentions towards their
patients, but their behaviour was
affected by events beyond their control,
which could lead to their omitting
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
information. The OHPs in this study
showed limited knowledge regarding F
toothpaste. They described
toothbrushing with F toothpaste as very
important, but focussed on plaque
removal. They also spoke less about F
toothpaste because they took for
granted that their patients’ knowledge
of and behaviour concerning
toothpaste were already in place. The
benefits of F toothpaste use for the
general population have strong
scientific support, and efforts should be
made to spread knowledge and
appropriate habits. (p.87, para.4)
Clinical relevance:
Programmes for oral health promotion
and education can increase individual’s
knowledge of and attitudes towards
oral health and can improve oral health
behaviour. OHPs are considered to be
the main source of knowledge
regarding oral health. In this study,
OHPs believed that patients used other
sources to obtain knowledge about oral
health and they even took it for granted
that patients already have the
knowledge. In their preventive work,
the OHPs should recognise their role
as oral health promoters with the
purpose of teaching patients the most
effective methods for self-care. (p.87,
para.5)
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Jonsson B,
Ohrn K, Oscarson
N, Lindberg P
Source
Population(s):
Participants were
recruited among
subjects with
moderate to
advanced
periodontitis referred
to the clinic and
examined during the
period March 2006March 2007. The
subjects were
referred from both
public and private
dentistry.
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): No information on
how exactly it was
randomised.
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
Oral health (clinical)
results:
Limitations
identified by
author:
None identified. The
author did not that
the power analyses
revealed that about
150 participants
were required for the
study although the
desired number was
not met. The original
power analysis was
based on an
intervention judged
as being less
effective than the
present one.
Year: 2009
Citation: Jönsson,
B., et al., The
effectiveness of an
individually tailored
oral health
educational
programme on oral
hygiene behaviour
in patients with
periodontal disease:
a blinded
randomisedcontrolled clinical
trial (one-year
follow-up). Journal
of Clinical
Periodontology,
2009. 36(12): p.
1025-1034 (Paper
One)
Setting: The study
was conducted in at
a specialist clinic for
periodontics in a
Swedish county with
approximately
320,000 inhabitants.
Location (urban or
rural): NR
Also:
Jönsson, B., et al.,
Evaluation of an
individually tailored
oral health
educational
Sample
characteristics:
Age: Intervention
group mean age =
52.4 (SD=8.4)
Control group mean
Report how confounding
factors were minimised:
Allocation was concealed but
the issue of contamination was
not explicitly addressed and it
does appear possible that
contamination could have
taken place. The article states
that there were "no statistically
significant differences in the
demographic variables or
background characteristics
between the groups".
Programme/Intervention
description:
What was delivered: The
programme comprised seven
separate components with
different tactics for tailoring
each individual’s personal
goals regarding oral health
and dental hygiene habits: i)
initiation and analysis of
knowledge ii) analysis of oral
Outcome name:
Gingival Index Global
Outcome definition:
The presence of
gingival inflammation
was recorded according
to the criteria for the
gingival index (GI) of
Loe & Silness (1963).
Both plaque index and
gingival index were
recorded on the buccal,
lingual, mesial and
distal tooth surfaces of
the teeth.
Outcome measure:
Gingival index (GI) of
Loe & Silness (1963)
Outcome measure
validated: As both the
Gingival and Plaque
Indexes are well
established in the
clinical practice of the
examiner there was no
calibration before the
study. However intraobservability reliability
Gingival Index Global:
Intervention group(s):
Baseline: 0.92 (Standard
Deviation (SD): 0.28)
Follow up (3 months): 0.27
9SD: 0.14)
End point (12 months):
0.21 (SD: 0.16)
Control group(s)
Baseline: 0.92 (SD: 0.23)
Follow up (3 months): 0.52
(SD: 0.20)
End point (12 months):
0.50 (SD: 0.17)
Baseline – 12 month mean
gain score difference: 0.27
(CI: 0.16-0.39) p<0.001.
Other mean gain score
differences also provided
Independent groups t-test
at the:
3 month follow-up: t=8.20,
p<0.001
12 month follow-up: t=9.61
p<0.001
Limitations
identified by review
team:
The reporting
periods were 3
month and 12
month. However 3
month was straight
after the treatment
and 12 months was
from baseline not
end of treatment.
Also there was a
maintenance period
for the treatment
group which lasted
202
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Study details
Population and
setting
Method of allocation to
intervention/control
programme on
periodontal health.
Journal of Clinical
Periodontology,
2010. 37(10): p.
912-919. (Paper
Two)
age = 50.1
(SD=10.3)
Sex: Intervention
group: Female = 32
(56.1%); Male = 25
(43.9%)
Control group:
Female = 28 (50%);
Male = 28 (50%)
Sexual orientation:
NR
Disability: NR
Ethnicity:
Intervention group:
Swedish = 46
(80.7%); Other = 11
(19.3%)
Control group:
Swedish = 50
(89.3%); Other = 6
(10.7%)
Religion: NR
Place of residence:
NR
Occupation: NR
Education:
Intervention group:
Elementary school =
14 (24.6%); High
school = 21 (36.8%);
University = 22
(38.6%)
Control group:
Elementary school =
13 (23.2%); High
hygiene behaviour iii) practice
of manual dexterity for oral
hygiene aids iv) individual
goals for oral hygiene
behaviour v) continuous selfmonitoring vi) generalisation of
behaviour vii) maintenance of
oral hygiene behaviour and
prevention of relapse. The
central theme of the
programme was tailoring the
treatment to each individual’s
problem, capacity and goals,
with subsequent guidance
towards appropriate and
effective oral hygiene habits.
Special emphasis was placed
on strategies that would fit as
naturally as possible into
everyday life (Paper One,
1028 para.5).
Theoretical basis: The
individually tailored oral health
educational programme was
based on the perspective of
behavioural medicine i.e. an
integration of cognitive
behavioural principles
(Bandura 1977, 1997,
Baranowski et al 2002) and
non-surgical periodontal
treatment.
By whom: 2 experienced
dental hygienists provided
both interventions, including
Jönsson, B., et al.,
Cost-effectiveness
of an individually
tailored oral health
educational
programme based
on cognitive
behavioural
strategies in nonsurgical periodontal
treatment. Journal
Of Clinical
Periodontology,
2012. 39(7): p. 659665. (Paper Three)
Country of study:
Sweden (western
country)
Aim of Study:
Paper One: To
evaluate the
effectiveness of an
individually tailored
oral health
educational
Outcome definitions
and method of
analysis
was tested through five
tests of the plaque and
gingival scores. 4 of the
five measurements
showed almost perfect
agreements (Cohen’s K
0.84-0.86) and one test
revealed a moderate
agreement (Cohen’s K
0.51).
Unit of measurement:
Index Score. The
highest score was 2.
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name:
Gingival Index Proximal
Outcome definition:
The presence of
gingival inflammation
was recorded according
to the criteria for the
gingival index (GI) of
Loe & Silness (1963).
Both plaque index and
gingival index were
recorded on the buccal,
lingual, mesial and
distal tooth surfaces of
the teeth.
Outcome measure:
Results
Notes by review
team
Gingival Index Proximal:
Intervention group(s):
Baseline:1.14 (SD: 0.27)
Follow up (3 months): 0.37
(SD: 0.17)
End point (12
months):0.72 (SD: 0.21)
until the 12 month
follow-up.
Control group(s)
Baseline: 1.13 (SD: 0.23)
Follow up (3 months): 0.28
(SD: 0.20)
End point (12 months):
0.69 (SD: ).20)
Baseline – 12 month mean
gain score difference: 0.40
(CI: 0.27-0.53) p<0.001
Other mean gain score
differences also provided
Independent groups t-test
at the:
3 month follow-up: t=9.50,
p<0.001
12 month follow-up: t=10.7
p<0.001
Paper One: Global
Plaque Index:
Intervention group(s):
Baseline:0.74 (SD: 0.34)
Follow up (3 months): 0.17
(SD: 0.11)
End point (12 months):
The setting in a
dental clinic in
Sweden is described
but there is no
information on
population
demographics.
Study in a western
country. Only 28 of
141 eligible patients
(just under 20%)
were excluded.
There is no
information on
whether there were
any differences
between those
included or excluded
but the excluded
sample is small.
Only 5% dropped
out overall. While all
but one of the dropouts was from the
intervention group
this was still only 9%
of the participants
within that group.
While the t-test
results in Paper One
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
programme for oral
hygiene self-care in
patients with chronic
periodontitis
compared with the
standard treatment.
school = 23 (41.1%);
19 (33.9%)
Socioeconomic
position: NR
Social capital: NR
non-surgical debridement for
both the experimental and the
control group.
To whom: 57 participants
How delivered: To create a
“dynamic dialogue” specific
skills in communication were
required and therefore
methods of Motivational
Interviewing were included.
When/where: Specialist clinic
in periodontics
Paper Two: To
evaluate an
individually tailored
oral health
educational
programme
(ITOHEP) on
periodontal health
compared with a
standard oral health
educational
programme. A
further aim was to
evaluate whether
both interventions
had a clinically
significant effect on
non-surgical
periodontal
treatment at 12 –
month follow-up.
Paper Three: The
aim of this cost
effectiveness
analysis (CEA),
performed form a
societal perspective,
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area): See
inclusion criteria.
State if eligible
population is
considered by the
study authors as
representative of
the source
population: No
information on
population
demographics so
this isn't clear.
Inclusion Criteria:
Participants clinically
diagnosed with
chronic periodontitis
and scheduled to
undergo a dental
hygiene treatment
(i.e. non-surgical
periodontal
How often: In the
experimental group the
median number of sessions for
the intervention and scaling
treatment was 5 (quartile
deviation 4-5) up to the 3
month follow-up and 9
*quartile deviation 8-9) when
maintenance care was
included up to the 12 month
follow-up
How long for: Up to 3 months
with maintenance care lasting
until the 12 month follow-up.
Control/Comparator
description:
What was delivered:
Standard treatment - The
control conditions were chosen
to be equivalent to the best
possible routine oral health
Outcome definitions
and method of
analysis
gingival index (GI) of
Loe & Silness (1963)
Outcome measure
validated: As both the
Gingival and Plaque
Indexes are well
established in the
clinical practice of the
examiner there was no
calibration before the
study. However intraobservability reliability
was tested through five
tests of the plaque and
gingival scores. 4 of the
five measurements
showed almost perfect
agreements (Cohen’s K
0.84-0.86) and one test
revealed a moderate
agreement (Cohen’s K
0.51).
Results
Notes by review
team
0.14 (SD: 0.13)
are provided in full,
results of statistical
tests in Paper Two
aren’t and only p
values are provided.
Unit of measurement:
Index Score. The
highest score was 2.
Paper Two: Plaque
Scores (full mouth):
Control group(s)
Baseline: 0.73 (SD: 0.31)
Follow up (3 months): 0.32
(SD: 0.22)
End point (12
months):0.31 (SD: 0.16)
Baseline – 12 month mean
gain score difference: 0.16
(CI: 0.03-0.30) p<0.001.
Other mean gain score
differences also provided
Independent groups t-test
at the:
3 month follow-up: t=4.36,
p<0.001
12 month follow-up: t=6.07
p<0.001
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Intervention group(s):
Baseline: 59 (SD: 18)
Follow up (3 months): 17
(SD: 10)
End point (12 months): 14
(SD: 12)
Outcome name:
Global Plaque Index
(Paper One) Plaque
Index Scores (full
Control group(s)
Baseline: 57 (SD: 17)
Follow up (3 months): 28
Evidence gaps: The
need for any
additional research
is not stated.
Source of funding:
All papers were
supported by the
Swedish Research
Council, Uppsala
County Council, the
authors’ institutions
and the Swedish
Patient Revenue
Fund for Research in
Preventive
Odontology. Paper
One was also
funded by the Pfizer
Oral Care Award.
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Study details
Population and
setting
Method of allocation to
intervention/control
was to compare
costs and
consequences of an
individually tailored
oral health
educational
programme
(ITOHEP) based on
cognitive
behavioural
strategies integrated
in non-surgical
periodontal
treatment compared
with a standard
treatment
programme.
debridement and
intervention
influencing oral
hygiene) aged
between 20 and 65,
literate in Swedish
and had a plaque
index (PLI)
according to Silness
and Loe (1964) of ≥
0.3.
preventive programme for
patients with periodontal
problems. The programme
used corresponded to the
description by Nyman et al
(1984) and by Rylander &
Lindhe (1997).
By whom: Dental Hygienist
To whom:56 participants
How delivered:
Demonstrations, discussions,
structured information, practice
and prescriptions.
When/where: Specialist clinic
in periodontics
How often: NR
How long for: NR
Study Design:
Parallel RCT
Quality Score (++,
+, or -): ++ (NOTE:
2 questions were
NR)
External
Validity(++, +, or -):
++
Exclusion Criteria:
Patients were
excluded if they
knew that they could
not be available
during any part of
the study period,
suffered from a
serious disease that
precluded regular
sessions, and if
explorative
periodontal surgery
was necessary
before the dental
hygiene treatment.
141 patients were
eligible of whom, 4
refused to participate
and 28 were
excluded.
% of selected
individuals agreed
Sample size at baseline:
Total sample N = 113
Intervention group N = 57
Control Group N = 56
Baseline comparisons
(report any baseline
differences between groups in
important confounders): There
was no statistically significant
difference in the demographic
variables or background
characteristics between the
groups.
Study sufficiently powered
(power calculations and
Outcome definitions
and method of
analysis
mouth) (Paper Two).
Outcome definition:
Both papers - The
presence of plaque was
recorded according to
Silness & Loe (1964)
Plaque Index.
Outcome measure:
Paper One only- Both
plaque index and
gingival index were
recorded on the buccal,
lingual, mesial and
distal tooth surfaces of
the teeth.
Paper Two only – In the
analyses all plaque
scores of 1 and above
were considered to be
a positive indicator of
plaque and the surface
was registered as
positive.
Outcome measure
validated: As both the
Gingival and Plaque
Indexes are well
established in the
clinical practice of the
examiner there was no
calibration before the
study. However intraobservability reliability
was tested through five
tests of the plaque and
gingival scores. 4 of the
Results
Notes by review
team
(SD: 17)
End point (12 months): 28
(SD: 13)
Differences between
intervention and control at
3 months significant at
P<0.001
Differences between
intervention and control at
12 months significant at
P<0.001
Mean % Plaque Index at
all sites:
 Successful NSPT
– 13 (Standard
Deviation (SD): 7)
 Incomplete NSPT
– 28 (SD: 15)
 P <0.001
Proximal Plaque Index:
Intervention group(s):
Baseline:1.01 (SD: 0.37)
Follow up (3 months): 0.29
(SD: 0.18)
End point (12 months):
0.23 (SD: 0.19)
Control group(s)
Baseline: 0.99 (SD: 0.35)
Follow up (3 months): 0.48
(SD: 0.28)
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Study details
Population and
setting
Method of allocation to
intervention/control
to participate: 80%
agreed to participate
and were eligible.
The remaining 20%
included 17% who
were excluded and
3% who refused to
participate.
provide details): A power
calculation with data from a
previous study (Johnson et al
2006) based on the detection
of a difference in the mean
Gingival Index of
interproximally of 20%
between treatment groups
indicted that 75 participants
were required in each group
(α=0.05, β=0.2). This
requirement was not met as
there were only 57 in the
experimental group and 56 in
the control group.
Potential sources
of bias:
Outcome definitions
and method of
analysis
five measurements
showed an almost
perfect agreement
(Cohen’s K 0.84-0.86)
and one test revealed a
moderate agreement
(Cohen’s K 0.51).
Unit of measurement:
Index Score
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name:
Proximal Plaque Index
Outcome definition:
The presence of
gingival inflammation
was recorded according
to the criteria for the
gingival index (GI) of
Loe & Silness (1963).
Both plaque index and
gingival index were
recorded on the buccal,
lingual, mesial and
distal tooth surfaces of
the teeth.
Outcome measure:
gingival index (GI) of
Loe & Silness (1963)
Outcome measure
validated: As both the
Results
Notes by review
team
End point (12 months):
0.49 (SD: 0.22)
Baseline – 12 month mean
gain score difference: 0.26
(CI: 0.10-0.43) p<0.001
Other mean gain score
differences also provided
Independent groups t-test
at the:
3 month follow-up: t=4.26,
p<0.001
12 month follow-up: t=6.87
p<0.001
Plaque Scores
(Interproximal sites):
Intervention group(s):
Baseline: 83 (SD: 18)
Follow up (3 months): 28
(SD: 16)
End point (12 months): 22
(SD: 17)
Control group(s)
Baseline: 79 (SD: 18)
Follow up (3 months): 42
(SD: 22)
End point (12 months): 45
(SD: 18)
Differences between
intervention and control at
3 months significant at
206
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Gingival and Plaque
Indexes are well
established in the
clinical practice of the
examiner there was no
calibration before the
study. However intraobservability reliability
was tested through five
tests of the plaque and
gingival scores. 4 of the
five measurements
showed an almost
perfect agreement
(Cohen’s K 0.84-0.86)
and one test revealed a
moderate agreement
(Cohen’s K 0.51).
Unit of measurement:
Index Score
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name:
Plaque Scores
(Interproximal scores)
Outcome definition:
Both papers - The
presence of plaque was
recorded according to
Silness & Loe (1964)
Plaque Index. In the
Results
Notes by review
team
P<0.001
Differences between
intervention and control at
12 months significant at
P<0.001
Mean Bleeding on
Probing – (full mouth):
Intervention group(s):
Baseline: 70 (SD: 20)
Follow up (3 months): 24
(SD: 12)
End point (12 months): 19
(SD: 13)
Control group(s)
Baseline: 75 (SD: 18)
Follow up (3 months): 33
(SD: 15)
End point (12 months): 29
(SD: 14)
Differences between
intervention and control at
3 months significant at
P<0.001
Differences between
intervention and control at
12 months significant at
P<0.001
Mean % Bleeding on
Probing at all sites:
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
analyses all plaque
scores of 1 and above
were considered to be
a positive indicator of
plaque and the surface
was registered as
positive.
Outcome measure:
Silness & Loe (1964)
Plaque Index
Outcome measure
validated: As both the
Gingival and Plaque
Indexes are well
established in the
clinical practice of the
examiner there was no
calibration before the
study. However intraobservability reliability
was tested through five
tests of the plaque and
gingival scores. 4 of the
five measurements
showed an almost
perfect agreement
(Cohen’s K 0.84-0.86)
and one test revealed a
moderate agreement
(Cohen’s K 0.51).
Unit of measurement:
Index Score.
Time points
measured: Baseline, 3
Results



Notes by review
team
Successful NSPT
– 14 (Standard
Deviation (SD): 5)
Incomplete NSPT
– 33 (SD: 14)
P <0.001
Mean Bleeding on
Probing – (interproximal
sites):
Intervention group(s):
Baseline: 87 (SD: 17)
Follow up (3 months): 35
(SD: 18)
End point (12 months): 27
(SD: 17)
Control group(s)
Baseline: 90 (SD: 13)
Follow up (3 months): 46
(SD: 20)
End point (12 months): 41
(SD: 19)
Differences between
intervention and control at
3 months significant at
P<0.01
Differences between
intervention and control at
12 months significant at
P<0.001
Probing Pocket Depth
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
month follow-up and 12
month follow-up
Outcome name: Mean
Bleeding on Probing –
Full mouth (BoP)
Outcome definition:
BoP was measured as
the presence/absence
of bleeding within 15 s
after pocket probing.
Outcome measure:
Presence or absence of
bleeding
Outcome measure
validated: No
Unit of measurement:
Presence or absence of
bleeding
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name: Mean
Bleeding on Probing –
Interproximal sites
Outcome definition:
BoP was measured as
the presence/absence
of bleeding within 15 s
after pocket probing.
Outcome measure:
Presence or absence of
Results
Notes by review
team
(PPD):
4-5 mm – all sites:
Intervention group(s):
Baseline: 31.0% (SD:
14.3)
Follow up (3 months):
12.7% (SD: 8.1)
End point (12 months):
10.4% (SD: 17)
4-5 mm – all sites:
Control group(s)
Baseline: 33.0% (14.0)
Follow up (3 months):
14.6% (SD: 11.4)
End point (12 months):
12.2% (SD: 19)
≥6 mm – all sites:
Intervention group(s):
Baseline: 9.2% (SD: 9.3)
Follow up (3 months):
1.6% (SD: 2.8)
End point (12 months):
1/6% (2.9)
≥6 mm – all sites:
Control group(s)
Baseline: 9.3% (11.0)
Follow up (3 months):
1.7% (SD: 3.5)
End point (12 months):
1.5% (SD: 3.2)
>4 mm – interproximal:
Intervention group(s):
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
bleeding
Outcome measure
validated: No
Unit of measurement:
Presence or absence of
bleeding – findings
reported as mean
percentages
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name:
Probing Pocket Depth
Outcome definition:
PPD was measured
using a manual
periodontal probe (CC
Williams Probe 1-2-3-57-8-9-10, Hu-Fridy®,
Chicago, IL, USA) on 6
surfaces of each tooth.
Outcome measure:
Findings reported as
mean percentages at 45 mm, ≥6 mm and for
interproximal > 4mm
Outcome measure
validated: No
Unit of measurement:
mm
Results
Notes by review
team
Baseline: 24.8% (SD:
17.2)
Follow up (3 months):
7.9% (SD: 6.9)
End point (12 months):
6.7% (SD: 6.9)
>4 mm – interproximal:
Control group(s)
Baseline: 27.7% (SD:
20.7)
Follow up (3 months):
8.5% (SD: 10.0)
End point (12 months):
6.7% (SD: 8.4)
No statistical differences
found between the groups
at either of the 3 stages
Proportion (%) of
pockets closed (PPD ≤
4mm):
All sites:
Intervention group(s):
Follow up (3 months): 69%
(SD: 21)
End point (12 months):
75% (SD: 20)
All sites:
Control group(s)
Follow up (3 months): 66%
(SD: 32)
End point (12 months):
76% (SD: 17)
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name:
Proportion of Pockets
Closed (PPD)
Outcome definition:
PPD was measured
using a manual
periodontal probe (CC
Williams Probe 1-2-3-57-8-9-10, Hu-Fridy®,
Chicago, IL, USA) on 6
surfaces of each tooth.
Outcome measure:
Findings reported as
mean percentages at
≤4 mm
Outcome measure
validated: No
Unit of measurement:
mm
Time points
measured: Baseline, 3
month follow-up and 12
month follow-up
Outcome name:
Successful NSPT (NonSurgical Peridontal
Treatment)
Outcome definition:
Results
Notes by review
team
Interproximal:
Intervention group(s):
Follow up (3 months): 68%
(SD: 22)
End point (12 months):
75% (SD: 21)
Interproximal:
Control group(s)
Follow up (3 months): 67%
(SD: 31)
End point (12 months):
77% (SD: 17)
No statistically significant
differences at either
timepoint.
Closed Pocket % at all
sites:
 Successful NSPT
– 14 (Standard
Deviation (SD): 5)
 Incomplete NSPT
– 33 (SD: 14)
 P <0.001
Successful NSPT (NonSurgical Peridontal
Treatment):
Logistic regression results:
211
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
To conclude whether
the interventions had a
clinically significant
effect i.e. reaching a
level of treatment
success at the 12month re-examination,
criteria for the
outcomes PLI, BoP,
and pocket closure
were formulated in
advance. To reach a
success level for nonsurgical periodontal
treatment (successfulNSPT), a classification
based on 3 classes for
the 3 outcomes were
established (below). To
be classified as
‘‘successful-NSPT’’, at
least 2 of the 3
outcomes had to be in
Class I, but none in
Class III. It was
assumed all
participants would
improve after treatment
and therefore the
individuals not fulfilling
the criteria for
‘‘successful-NSPT’’
were classified into the
group, ‘‘incompleteNSPT’’. All the
participants were
Results
Notes by review
team
Plaque index (0-100%):
Odds Ratio (POR)=0.95
(95% CI= 0.92-0.97,
p=0.001
Bleeding on probing (0100%): OR=1.05 (CI=0.0331.7, p=0.979)
Percentage of PPD>5mm
(0-100%): OR=0.98
(CI=0.93-1.04, p=0.624)
ITOHEP intervention v ST
intervention: )R=4.22
(CI=1.77-10.1, p=0.001)
Behavioural results:
Attrition details:
Indicate the number lost to
follow up and whether the
proportion lost to follow-up
differed by group (i.e.
intervention vs control)
Conclusion:
An individually tailored oral
health educational
programme was more
effective for achieving
proper long-term oral
hygiene self-care
behaviour and resulted in
a larger reduction in
gingival inflammation than
standard treatment. The
differences between
212
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
grouped as either
‘‘successful-NSPT’’ or
‘‘incomplete-NSPT’’.
Outcome measure:
Class 1: % closed
pocket= >75%; %
bleeding on probing=
≤15%; % plaque index=
≤20%
Class 2: % closed
pocket= ≥65%; %
bleeding on probing=
≤25%; % plaque index=
≤29%
Class 3: % closed
pocket= <65%; %
bleeding on probing=
>25%; % plaque index=
>29%
Outcome measure
validated: No
Unit of measurement:
Dichotomous variable
(“successful” or
“incomplete NSPT”)
based on percentage
scores explained
above. Used in a
logistic regression
model.
Time points
measured: 12 month
re-examination
Results
Notes by review
team
groups remained
throughout the 1 year
study period. Hence, the
hypothesis for the study
was confirmed.
The present study aimed
to evaluate 2 different oral
hygiene behavioural
change programmes in
non-surgical periodontal
treatment regarding
periodontal health. After
treatment, the individually
ITOHEP group had lower
BoP scores than the
standard health
educational programme
group with the largest
differences being for the
interproximal surfaces. For
the clinical outcome
variable PPD reduction,
both groups improved
equally. When all clinical
variables were considered,
more individuals in the
individually tailored oral
health educational group
attained ‘‘successfulNSPT’’ level (due to lower
plaque and BoP scores),
and more individuals
attaining this ‘‘successfulNSPT’’ level reported good
or very good oral health
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Method of analysis
(indicate if ITT or
completer analysis was
used and if adjustments
were made for any
baseline differences in
important confounders):
Results
Notes by review
team
after treatment than the
‘‘incomplete-NSPT’’ group.
An intention-to-treat
analysis was applied
where the attrition rates
were imputed with a
linear interpolation
imputation method for
gingival and plaque
index data and with the
method of last value
carried forward for oral
health behaviour.
For “successful NSPT”
(Paper Two) a binary
logistic regression
model was used.
Selected variables were
Oral health educational
treatment groups, PLI,
and BoP at baseline
examination, although
for closed pocket, the
percentage PPD45mm
was used.
Gingival Index Global,
Gingival Index
Proximal, Global
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Plaque Index, Proximal
Plaque index and
interp-proximal plaque
scores were all
analysed with separate
2 (experimental group/
control group) x 3
(baseline/ 3 month
post-treatment/ 1-year
follow-up) repeated
measures ANOVA. The
mean gain-score
differences were
analysed by the
Independent group’s ttest. This was also
used for the Paper Two
outputs: interproximal
plaque scores and full
mouth plaque scores
Results
Notes by review
team
Treatment effects on
Bleeding on Probing
(Paper Two) were
estimated with separate
2 (experimental
group/control group) x 3
(baseline/3 month posttreatment /1 year
follow-up) repeated
measures analyses of
variance (ANOVA
repeated measure) and
subsequent
Bonferroni’s post hoc
tests.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author: Jonsson,
B, Oscarson, N,
Ohrn, K
Source
Population(s):
Country of study
(include if developed
or non-developed)
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): Lottery
Outcomes (include
details of all relevant
outcome measures
and whether measures
are objective or
subjective or otherwise
validated):
For each outcome
report
Limitations identified
by author:
Means, SDs, pvalues, CIs, Effect
sizes, SEs
The patients in both
groups may be
considered as
individuals with
difficulties to comply with
recommendations.
Before the start of the
study, they had all
received periodontal
treatment 1 or 2 years
earlier and in spite of
that treatment they still
had insufficient
compliance and
progress of their
periodontal disease.
Year: 2006
Citation: Jonsson,
B., et al., Improved
compliance and
self-care in patients
with periodontitis--a
randomised control
trial. International
Journal of Dental
Hygiene, 2006. 4(2)
p. 77-83.
Country of study:
Sweden
Aim of Study: To
test an intervention
emanating from the
CSCCM, to
encourage
participants to
increase their
responsibility for
their oral self-care.
Study Design: The
study was a
Setting: The
Department of
Periodontology, the
County Council of
Uppsala, Sweden
Location (urban or
rural): NR
Sample
characteristics:
Age: Intervention
group: 54.8 ± 11.7
(25–74)
Control group: 58.1 ±
9.9 (41–78)
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education: NR
Report how confounding
factors were minimised:
There were no significant
baseline imbalances. There is
no information on whether
allocation was concealed or
whether contamination was
taken into account. Single
blinding was used.
Programme/Intervention
description:
What was delivered: An initial
questionnaire for baseline
measures of oral care, these
were also administered at the
end. A clinical assessment at
the beginning and the end
administered by the same
examiner. CSCCM was used to
enhance patient compliance
regarding their self-care
behaviours.
Visit 1: Initiation Phase, patient
Outcome name: Oral
Self-care habits
Outcome definition:
No. of times brushed
teeth per day and
reported interdental
cleaning per week
Outcome measure:
reported interdental
cleaning per week
Outcome measure
validated: Unclear
Unit of measurement:
Number of times
brushed teeth per day
Time points
measured: Start and
end
Outcome name:
Plaque index
Outcome definition:
Plaque index and (PLI)
and percentage
Oral health (clinical)
results:
Plaque index
Intervention group(s)
Baseline 0.59 (SD:
±0.17)
(CI 0.51-0.67)
End point: 0.25 (SD:
± 0.11)
(CI 0.20-0.30)
Control group(s)
Baseline:0.59 (SD: ±
0.29)
(CI 0.44-0.75)
End point: 0.33 (SD:
± 0.11)
(CI 0.27-0.39)
There was a
statistically significant
difference in PLI
between the IV group
Individuals in the IV
group obtained one
extra visit to confirm the
commitment.
The study population
was quite small, but still
significant results could
be demonstrated
regarding interdental
cleaning and plaque
reduction, however, the
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
randomised singleblind control trial to
test an intervention
based on CSCCM
(Client Self-care
Commitment
Model)
Socioeconomic
position: NR
Social capital: NR
presented their own explanatory
model of self-care methods and
disease processes, experiences
of earlier treatments, and their
beliefs about the reasons for
disease progress. There is then
an Assessment Phase,
participants then negotiate a
pan with the DH and then
formulate a commitment plan
where the DH assisted the
patient to establish self-selected
goals.
Quality Score (++,
+, or -):
External
Validity(++, +, or ):
+
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): NR
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR
Inclusion Criteria:
Individuals 20–80
years of age with
insufficient
compliance, which
was defined as
individuals who
reported interdental
cleaning (tooth picks
or interdental
brushes) less than
five times a week
combined with a
dental plaque score
>0.20 according to
Silness and Lo¨e (29).
Visit 2: At the next visit (after 1–
2 weeks) the client reported
their compliance with the
established self-care
commitment. Oral hygiene
status was checked.
Visit 3: The aim with the visit
was to check if the patients had
found the self-selected goals
realistic and if any changes
were necessary.
Visit 4: The final evaluation was
performed 12–14 weeks after
the first visit. The patients were
given the second questionnaire.
The same dentist performed the
same clinical assessments as at
baseline. The commitment was
also analysed.
Outcome definitions
and method of
analysis
reduction of PLI
Outcome measure:
Plaque index
Outcome measure
validated: Unclear
Unit of measurement:
percentage reduction
of PLI
Time points
measured: Start and
end
Outcome name:
Gingival index and
bleeding on probing
Outcome definition:
Gingival Index (GI),
bleeding on probing
(BoP)
Outcome measure:
percentage reduction
of GI and BoP at
baseline and final
examination
Outcome measure
validated: Unclear
Unit of measurement:
Gingival Index (GI),
bleeding on probing
(BoP)
Time points
measured: Start and
end
Outcome name:
Periodontal pocket
Results
Notes by review team
(0.25 ± 0.11) and the
C group (0.33 ± 0.11)
(t = 2.21; d.f. = 33; P
= 0.03) at the final
examination. The
plaque reduction was
significantly higher for
the IV group (56%)
compared with the C
group (35%) (t =
2.49; d.f. = 33; P =
0.02) (Table 3).
However, a
statistically significant
reduction of PLI was
seen at the final
examination
compared with
baseline for both
groups (IV: t = 8.37;
d.f. = 18; P < 0.0001)
(C: t = 3.88; d.f. = 15;
P = 0.002).
sample size may be too
limited to show
significant reduction in
GI and BoP
Gingival Index
Intervention group(s)
Baseline 0.73 (SD:
±0.14)
(CI 0.66-0.79)
End point: 0.38 (SD:
± 0.20)
(CI 0.28-0.48)
Control group(s)
Baseline:0.65 (SD: ±
Limitations identified
by review team:
The source area is given
as Sweden but no more
detail than this.
Examples of items from
the questionnaires are
not given.
Only the participants
were blinded to the aims
and objectives of the
experiment. It is not
clear whether exposure
to the intervention or
comparison was
adequate and there is no
information on
contamination.
Intervention group
received an extra followup appointment.
Drop-out rates were not
recorded.
It is unclear whether the
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
To avoid missing the
individuals who overreported their
interdental cleaning,
patients who reported
interdental cleaning
‡5 times a week but
nevertheless showed
a dental plaque
scores >0.40, were
also included. Dental
plaque scores >0.40
has been considered
by Lang et al. (30) as
a marker for
insufficient plaque
control and increasing
risk for disease
progression.
Bleeding on probing
(BoP) >25% and
teeth with recurrent
pocket depth >4 mm
was considered as a
progress of the
periodontal disease in
concordance with
Lang et al. (30).
Theoretical basis: The Client
Self-care Commitment Model
(CSCCM)
By whom: The same examiner
and an experienced dental
hygienist.
To whom: Participants
How delivered: Used interview
strategies, appropriate dental
aids were introduced,
established self-selected goals
and had clinical assessments.
Framed the healthcare
message either self-care or
patients made decisions with
the DH.
When/where: Department of
Periodontology, the County
Council of Uppsala, Sweden
How often: 4 visits. Visit 2 was
1-2 weeks after visit 1. Visit 3
was 4 weeks after baseline and
written commitment. Visit 4 was
12-14 weeks after the first visit.
How long for: 12-14 weeks
Exclusion Criteria:
NR
% of selected
individuals agreed
Control/Comparator
description:
What was delivered: An initial
questionnaire for baseline
measures of oral care, these
were also administered at the
end. A clinical assessment at
the beginning and the end
administered by the same
Outcome definitions
and method of
analysis
depth
Outcome definition:
Number of pockets
more than 4mm at
baseline and final
examination
Outcome measure:
Number of pockets
more than 4mm
Outcome measure
validated: Unclear
Unit of measurement:
Number of pockets
more than 4mm at
baseline and final
examination
Time points
measured: Start and
end
Method of analysis
(indicate if ITT or
completer analysis was
used and if
adjustments were
made for any baseline
differences in important
confounders): ChiSquare and T-Tests
Results
Notes by review team
0.23)
(CI 0.53-0.77)
End point: 0.39 (SD:
± 0.14)
(CI 0.39-0.46)
outcome measures were
reliable.
In both groups, there
was a statistically
significant reduction
of GI (IV: t = 7.59; d.f.
= 18; P < 0.0001) (C:
t = 4.07; d.f. = 15; P =
0.001) and BoP (IV: t
= 9.30; d.f. = 18; P <
0.0001) (C: t = 5.07;
d.f. = 15; P = 0.0001).
No statistically
significant difference
between the IV and
the C groups with
regard to GI or BoP
could be found (Table
4).
The setting was not in
the UK although
Swedish dental practices
don’t appear to differ too
much from British ones.
Evidence gaps:
It would be of interest to
evaluate the result of the
CSCCM in a longitudinal
study to investigate if the
results remain after an
extended period of time.
it would be of interest to
study the use of CSCCM
in a larger study
population
Source of funding: NR
Bleeding on probe
Intervention group(s)
Baseline 46.8 (SD:
±13.8)
(CI 40.2-53.5)
End point: 18.7 (SD:
± 8.3)
(CI 14.7-22.8)
Control group(s)
Baseline:39.0 (SD: ±
218
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
to participate: 2 of
the patients dropped
out; one became ill,
and one declined
treatment at the clinic
for Periodontology.
examiner.
Potential sources of
bias:
Visit 1: The latest periodontal
status were demonstrated,
discussed and compared with
previous status. The oral
hygiene instructions were
performed, controlled and
adjusted if necessary
Visit 2: At the next visit (after 1–
2 weeks), the oral hygiene
status was checked.
Visit 3: The final evaluation was
performed 12–14 weeks after
the first visit. The patients were
given the second questionnaire.
The same dentist performed the
same clinical assessments as at
baseline
By whom: The same examiner
and an experienced dental
hygienist.
To whom: Participants
How delivered: Information
was given on oral hygiene.
When/where: Department of
Periodontology, the County
Council of Uppsala, Sweden
How often: 12-14 weeks
How long for: 3 visits: Visit 2
was 1-2 weeks after the first
visit. Visit 3 was 12-14 weeks
after the first visit.
Outcome definitions
and method of
analysis
Results
Notes by review team
16.0)
(CI 30.5-47.5)
End point: 16.3 (SD:
± 5.7)
(CI 13.3-19.3)
In both groups, there
was a statistically
significant reduction
of GI (IV: t = 7.59; d.f.
= 18; P < 0.0001) (C:
t = 4.07; d.f. = 15; P =
0.001) and BoP (IV: t
= 9.30; d.f. = 18; P <
0.0001) (C: t = 5.07;
d.f. = 15; P = 0.0001).
No statistically
significant difference
between the IV and
the C groups with
regard to GI or BoP
could be found (Table
4).
Periodontal pocket
depth
Intervention group(s)
Baseline 5.8 (SD:
±3.9)
(CI 3.9-7.7)
End point: -2.7 (SD: ±
3.0)
(CI 1.2-4.1)
Control group(s)
219
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Sample size at baseline:
Total sample N = 35
Intervention group N = 19
Control Group N = 16
Baseline comparisons (report
any baseline differences
between groups in important
confounders): No significant
imbalances
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of
analysis
Results
Notes by review team
Baseline:4.9 (SD: ±
6.7)
(CI 1.3-8.4)
End point: -2.9 (SD: ±
3.1)
(CI 1.2-4.5)
Behavioural results:
Oral self-care habits
– increase in use of
interdental cleaning
Intervention group(s)
Baseline: 4
End point: 19
Control group(s)
Baseline: 10
End point: 11
A significantly higher
proportion of patients
in the IV group (79%)
increased their use of
interdental cleaning
from baseline to the
final examination
compared with
patients in the C
group (6%) (v2 =
6.93; d.f. = 1; P =
0.00 8) (Table 2). A
total of 78% in the IV
group reported that
the written
220
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
commitment did
influence their oral
self-care behaviours
in a positive way.
79% found it valuable
to establish selfselected goals for
oral self-care.
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control): Loss of 2
participants, NR in
which groups.
Conclusion: The
CSCCM enhanced
the client participation
in the treatment
process and
stimulated to
improved oral selfcare behaviours. In
addition, the model
contributed to a
reduction in
periodontal pockets.
Patients in the IV
group increased their
interdental cleaning
221
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
and reduced their PLI
significantly
compared with those
in the C group. In
addition, there was a
tendency to higher
reduction of BoP in
the IV group although
it did not reach a
significant level. The
majority of the
individuals in the IV
group reported that
the written
commitment had
influenced on their
oral self-care habits
in a positive direction,
which was confirmed
with a significant
reduction of PLI.
222
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Author: B. Jonsson, K
Ohrn, N Oscarson, P
Lindberg
Source
Population(s):
Sweden
Year: 2009
Setting: This study
was conducted at the
Department of
Periodontology in a
Swedish county
council. The patients
were referred to the
clinic for periodontal
treatment. (p.169
para.7)
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): N/A. (no control
group)
Outcomes (include
details of all relevant
outcome measures
and whether
measures are
objective or subjective
or otherwise
validated):
Citation: Jonsson at
al An individually
tailored treatment
programme for
improved oral
hygiene: introduction
of a new course of
action in health
education for patients
with periodontitis.
International journal of
dental hygiene, 2009.
Country of study:
Sweden
Aim of Study: The
aim of the present
study was to describe
and evaluate an
individually tailored
treatment programme
based on a
behavioural medicine
approach for oral
hygiene self-care in
patients with chronic
periodontitis. More
specifically, this study
Location (urban or
rural): NR
Sample
characteristics:
Sample
characteristics:
Age: 50 and 60
Sex: Male and
Female
Sexual orientation:
Not stated
Disability: Not stated
Ethnicity: Not stated
Religion: Not stated
Place of residence:
Not stated
Occupation: Not
stated
Education: Not
Report how confounding
factors were minimised:
[quality assessment]
Programme/Intervention
description:
What was delivered: The
intervention included the
following elements: a) an
interview to ascertain the
patient’s knowledge of
periodontal disease, self-care
habits and attitude towards oral
hygiene, as well as to discuss
long-term goals; b) analysis of
oral hygiene behaviour based
on the above data by the dental
hygienist – disclosing solution
was used to illustrate the
current oral biofilm and initiate
a discussed related to oral
hygiene aids; c) practice of
manual dexterity once patient’s
oral hygiene aids had been
chosen; d) the formulation of an
action plan for oral self-care
before the next session was
Outcome name: 1)
Plaque indices (PI)
Outcome definition:
Calculated for
vestibular and lingual
surfaces reflected the
toothbrushing
behaviour and interproximal cleaning
behaviour (p.168
para.2).
Outcome measure: A
modified three-grade
(0-2) plaque index
according to Silness
and Loe was used
(p.168 para.2). A HuFridy Williams probe
was used (p.168
para.3).
Outcome measure
validated: NR
Unit of
measurement: Index
score used to
Results
1) Plaque indices and 2)
Gingival indices
Mrs A:
When the intervention
was introduced at week
four (a new
toothbrushing technique
was introduced and
brushing skills were
practised), a rapid
decrease for both PI
and GI occurred for the
vestibular and lingual
surfaces. During week
five and six when
interdental cleaning aids
were introduced a rapid
decrease of PI occurred
from 1.1 to 0.3. As could
be expected, there was
a delay in the decrease
in the GI but it followed
the PI closely. (p.170
para.2)
The total PI showed an
average value of 0.58
(Baseline phase), 0.50
(Analysis and applied
skill phase), 0.16
(Generalisation phase)
and 0.18 (Follow-up ⁄
maintenance phase)
Notes by review
team
Limitations
identified by
author:
Experimental singlecase studies do not
replace experimental
group studies and it
is not possible to
generalise the result
to a larger group.
(p.174 para.3)
Limitations
identified by review
team:
As noted by the
author the study is
not externally valid.
Evidence gaps: NR
Source of funding:
The study was
supported by the
dental healthcare
administration in
Uppsala County
Council and the
Sture Nyman
Foundation. (p.174
para.5)
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Oral Health: Approaches for general practice teams on promoting oral health
aims to describe the
programmes’ shortand long-term effect
on oral hygiene
behaviour, dental
plaque control,
gingival and
periodontal health and
individually long-term
goals in 2
experimental singlecase studies. (p.167
para.7)
Study Design: 2
experimental singlecase studies with
multiple-baselines
over 2 different selfadministered oral
hygiene behaviours
were
conducted.(p.167
para.8)
stated
Socioeconomic
position: Not stated
Social capital: Not
stated
Smoking habits:
Non-smoker and
smoker (20 cigarettes
per day)
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area):
Quality Score (++, +,
or -): -
State if eligible
population is
considered by the
study authors as
representative of
the source
population: N/A. –
this is a study of just
2 cases
External Validity(++,
+, or -): -
Inclusion Criteria:
NR
Exclusion Criteria:
NR
% of selected
individuals agreed
to participate: N/A.
formulated; e) continuous selfmonitoring via a short
structured diary; and f)
generalisation of behaviour by
coordinating all the self-care
aids that had been introduced.
Theoretical basis: Social
Cognitive Theory is an example
of a theoretical framework that
is commonly used for the
description and understanding
of different factors influencing
health behaviour. To prevent
periodontal disease there is a
need for lifelong adherence to
effective oral hygiene habits.
Consequently it is crucial to
develop and test integrated
cognitive/behavioural
approaches prospective
longitudinal studies adapted to
regular periodontal treatment.
This implies that strategies are
based on individual factors
(psychological, contextual and
physiological) that are related
to health outcomes of interest
and derived from individual
assessments. (p.167 paras 3
and 5)
By whom: The intervention
was conducted by an
experienced dental hygienist
(the first author) who also
performed the scaling
treatment. The intervention was
supervised by a psychologist.
The clinical assessments were
performed by the same
calculate mean value
– maximum was 2
(p.168 para.2)
Time points
measured: Every
week for 8 weeks,
then weeks 13, 21, 40,
52, 68 and 104 (p.171
Fig 1)
Outcome name: 2)
Gingival indices
Outcome definition:
As with plaque
indices, calculated for
vestibular and lingual
surfaces reflected the
toothbrushing
behaviour and interproximal cleaning
behaviour (p.168
para.2).
Outcome measure: A
modified version of
Loe and Silness threegrade (0-2) gingival
index was used. A HuFridy Williams probe
was used (p.168
para.3).
Outcome measure
validated: NR
Unit of
measurement: Index
score used to
calculate mean value
– maximum was 2
respectively. The
corresponding figures of
the gingival index were
0.64 (Baseline phase),
0.55 Analysis and
applied skill phase),
0.15 (Generalization
phase) and 0.20
(Follow-up ⁄
maintenance phase)
respectively. (p.171
para.1)
Mr B:
When the intervention
was introduced during
week 4 (a new
toothbrushing technique
was introduced and
brushing skills was
practise), a rapid
decrease for both PI
and GI occurred for the
vestibular and lingual
surfaces (Fig. 2a). At
week five when
toothpicks were
introduced a rapid
change in PI occurred
from a mean of 1.5 to
0.6 (Fig. 2b). As
expected, there was a
delay in the decrease in
the GI, but it followed
the PI closely. (p.172
para.2)
The total PI showed an
average value of 1.18
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Oral Health: Approaches for general practice teams on promoting oral health
Potential sources of
bias:
examiner, a specialist in
Periodontology, for both
subjects throughout the course
of the study. (p.169 para.7)
To whom: 2 participants
How delivered: An integration
of cognitive behavioural
principles with regular
periodontal treatment was
made when the treatment
programme organised. In order
to facilitate this strategy
Motivational Interviewing (MI)
techniques were used. (p.168
para.6)
When/where: The Department
of Periodontology in a Swedish
county council. (p.169 para.7)
How often: Baseline consisted
of 3 sessions in a 3 week
period. This was followed by
analysis of applied skills
(intervention component I-V)
which also included 3 (45-75
min) sessions over a 3 week
period. Generalisation
(components VI-VII) occurred
over 2 to 3 sessions (each 4575 min long) with the last
session undertaken 1 month
after the previous session. 3,
12 and 24 month follow-up
examinations were also
included and 2 maintenance
care sessions in between
(p.170 Table 1).
How long for: Not absolutely
clear because generalisation
sessions could vary in timing
(p.168 para.2)
Time points
measured: Every
week for 8 weeks,
then weeks 13, 21, 40,
52, 68 and 104 (p.171
Fig 1)
Outcome name: 3)
Probing Pocket Depth
Outcome definition:
NR
Outcome measure:
Measured at 6
surfaces of each tooth
Outcome measure
validated: NR
Unit of
measurement: NR
Time points
measured: Baseline,
3 month, 1 year and 2
year follow-ups
Outcome name: 4)
Bleeding on probing
Outcome definition:
NR
Outcome measure:
Measured in
connection with
measurement of
periodontal pockets
(p.168 para.3)
Outcome measure
validated: NR
(Baseline phase), 0.92
(Analysis and applied
skill phase), 0.27
(Generalisation phase)
and 0.13 (Follow-up ⁄
maintenance phase)
respectively.
The corresponding
figures of the gingival
index were 1.17
(Baseline phase), 1.21
(Analysis and applied
skill phase), 0.55
(Generalisation phase)
and 0.21 (Follow-up ⁄
maintenance phase)
respectively.
3) Probing Pocket
Depth (% probing ≥
5mm) (p.171 Table 3)
Mrs A:
Baseline:11%
Follow up (3 months):
2%
Follow up (12 months):
2%
End point (24 months):
1%
Mr B:
Baseline: 26%
Follow up (3 months):
2%
Follow up (12 months):
2%
End point (24 months):
4%
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Oral Health: Approaches for general practice teams on promoting oral health
and number but the
intervention itself would have
lasted about 2-3 months with
an additional 3 weeks for the
baseline. This was then
followed by a 24 month
maintenance period.
Sample size at baseline:
Total sample N = 2
Baseline comparisons (report
any baseline differences
between groups in important
confounders): N/A. – there are
only 2 cases
Study sufficiently powered
(power calculations and provide
details):N/A
Unit of
measurement: NR
4) Bleeding on probing
(p.171 Table 3)
Time points
measured: NR
Mrs A:
Baseline: 68%
Follow up (3 months):
10%
Follow up (12 months):
16%
End point (24 months):
6%
Outcome name: 5)
Oral Hygiene
Behaviour
Outcome definition:
NR
Outcome measure:
Questionnaire which
covered oral self-care
habits such as
frequency of
toothbrushing and
interdental cleaning,
type of toothbrush and
interdental cleaning
aid and when and
where the oral
cleaning was
performed. (p.168
para.4)
Outcome measure
validated: NR
Unit of
measurement: NR
Time points
measured: A
questionnaire was
completed by the
participants
immediately after the
first clinical
Mr B:
Baseline: 83%
Follow up (3 months):
16%
Follow up (12 months):
15%
End point (24 months):
10%
Behavioural results:
Outcome name: 5)
Oral Hygiene Behaviour
At baseline Mrs A
reported toothbrushing
twice a day using a
manual toothbrush and
disclosed an insufficient
toothbrushing
technique. She used
dental floss 6 times per
week and toothpicks
after meals.
She changed technique
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Oral Health: Approaches for general practice teams on promoting oral health
examination and
before the clinical
examination at the 3,
12, and 24 month
follow-ups. (p.168
para.4)
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders):
To conclude whether
the intervention
programme had a
clinically significant
effect, criteria for
improvement were
formulated in advance.
The mean PI (for all
calculated tooth
surfaces) should be
reduced to a mean
level close to 0.20. For
clinically significant
periodontal
improvement the
mean BoP index
should be below 20%
of the total number of
tooth surfaces. Visual
inspection of the
changes in mean,
level, trend and
latency of change
during the intervention
and by the 1 year
follow-up toothpicks
were used as the main
daily interdental
cleaning aids and
interdental brushes
were used 2-3 times per
week. At the 2 year
follow-up she cleaned
her teeth with a power
toothbrush once a day
and interdental cleaning
was performed using
toothpicks and
interdental brushes on a
daily basis (p.170
para.1).
At baseline Mr B
reported brushing his
teeth with a manual
toothbrush twice a day
and he used dental floss
and toothpicks very
sparsely. During the
intervention he
improved his
toothbrushing technique
and he chose to clean
between his teeth on a
daily basis. This
remained the case
throughout the follow-up
periods although the
times when he did it
changed (p.172 para.1).
Attrition details:
227
Oral Health: Approaches for general practice teams on promoting oral health
across the different
phases was applied
for judgement of the
intervention effect.
(p.169 para.9)
N/A.
Conclusion: The main
result from the present
study was that the
individually tailored
treatments based on an
integrated behavioural
and oral health
approach could be
successfully applied in
the 2 study participants.
Both reached the
clinical significant
improvement for plaque
(22, 24, 25), suggesting
that the intervention was
effective to improve oral
hygiene practise.
Further, the pre-decided
criteria for BoP were
achieved. The positive
results remained stable
throughout the 2-year
study period for both
participants. (p.173
para.3).
The individually tailored
treatment programme
seems efficacious and
useful to improve longterm adherence to oral
hygiene in periodontal
treatment. Such
programmes need to
focus on the patient
perspective since all
actions originate from
228
Oral Health: Approaches for general practice teams on promoting oral health
the patient thoughts,
intermediate and longterm goals.
Finally, periodontal
health was substantially
improved based on the
selected clinical criteria.
The programme is now
being tested in a
randomised controlled
trial and by doing so it is
also being adapted to a
larger clinical practice
sample. (p.174 para.4)
229
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Kakudate,
N. et al
Source
Population(s):
Patients with mild to
moderate chronic
periodontitis who were
visiting a private
dental clinic in
Sapporo (Japan) for
periodontal treatment
Method of allocation:
Randomisation was performed
blindly according to a random
numbers table
Outcomes (include
details of all relevant
outcome measures
and whether
measures are
objective or
subjective or
otherwise validated):
Oral health (clinical)
results:
PCR value %: Mean
(SD), P-value
Limitations identified
by author:
Year: 2009
Citation: Kakudate,
N., Morita,
Manabu., Sugai,
Makoto., and M.
Kawanami.
Systematic
cognitive
behavioural
approach for oral
hygiene instruction:
A short-term study.
Patient Education
and Counseling 74
(2009) 191–196
Country of study:
Japan
Aim of Study:
Determine whether
a six-step
behavioural
cognitive method is
more effective than
traditional oral
hygiene instruction
Study Design:
Parallel RCT
Setting: private dental
clinic in Sapporo
(Japan)
Location (urban or
rural): Sapporo
(Japan)
Sample
characteristics:
Age: 37 – 76 years.
Mean age = 56.4
Sex: 22 Male and 16
female
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Sapporo, Japan
Occupation: NR
Education: NR
Socioeconomic
Report how confounding
factors were minimised: NR
Programme/Intervention
description:
What was delivered: The
subjects received counselling
using the six-step method
(modified for periodontal
patients) for 10 mins following
traditional oral hygiene
instruction (including
toothbrushing instruction) which
lasted for 20 mins
Theoretical basis: Cognitive
behaviour approach –
Farquhar’s six step method
(modified to be applicable to
periodontal patients):
Step 1: identifying the problem
Step 2: creating confidence and
commitment
Step 3: Increasing awareness of
behaviour
Step 4: Developing and
implementing the action plan
Step 5: Evaluating the plan
Step 6: Maintaining change and
preventing relapse
Outcome name:
Plaque index
Outcome definition:
Plaque index was
evaluated using the
Plaque Control Record
(PCR) of O’Leary et al.
Outcome measure:
PCR
Outcome measure
validated: NR
Unit of measurement:
%
Time points
measured: Performed
twice with a 1 week
interval. At first
instruction and final
instruction
Outcome name: Daily
frequency of tooth
brushing (behavioural
Total sample: NR
Baseline: NR
Follow up (all time
points): NR
End point: NR
Intervention
group(s): n=18
Baseline: 56.90
(15.75)
Follow up (all time
points): N/A
End point: 15.98
(8.71), p< 0.001
(Wilcoxon’s signed
rank test) and p<0.01
(ANCOVA)
Control group(s):
n=20
Baseline: 49.78
(13.35)
Follow up (all time
points): N/A
End point: 20.82
(7.93), p<0.001
(Wilcoxon’s signed
rank test)
Behavioural results:
Traditional oral
hygiene instruction
was carried out by one
dental hygienist in
both groups, whereas
six step method was
performed by one
dentist. It is generally
imagined that a dentist
is perceived as more
trustworthy than a
dental hygienist by
patients, which might
have positively
influenced intervention
outcomes (p.195).
The study focussed on
patients with mild to
moderate chronic
periodontitis. There
might be a difference
between self-efficacy
of patients with mild to
moderate chronic
periodontitis and that
of patients with severe
chronic periodontitis.
Longer follow-up
studies are required
because the
230
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Quality Score (++,
+, or -): +
position: NR
Social capital: NR
External
Validity(++, +, or ): +
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area): Patients
with mild to moderate
chronic periodontitis
according to the
criteria of Hirschfeld
and Wasserman
(1978) and slight or
moderate periodontitis
according to the
previous criteria of the
ADA (2006)
By whom: Counselling by a
dentist. Traditional oral hygiene
instruction by a dental hygienist
To whom: Patient
How delivered: Step 1 and 2 at
first visit. Step 3 and 4 at second
visit. Step 5 at third visit
Tooth brushing instructions were
based on the Bass method.
When/where: Private dental
clinic, Japan
How often: Once a week for 3
weeks
How long for: 20 mins
(instruction) plus 10 mins
(counselling)
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR
Inclusion Criteria:
Patients with mild to
moderate chronic
periodontitis according
to the criteria of
Hirschfeld and
Wasserman (1978)
Control/Comparator
description:
What was delivered:
Traditional oral hygiene
instruction for 20 mins (including
toothbrushing instruction)
By whom: Dental hygienist
To whom: Patient
How delivered: Tooth brushing
instructions were based on the
Bass method.
When/where: Private dental
clinic, Japan
How often: Once a week for 3
weeks
How long for: 20 mins
Sample size at baseline:
Outcome definitions
and method of
analysis
characteristics)
Outcome definition:
Daily frequency of tooth
brushing
Outcome measure:
Number of times
Outcome measure
validated: NR
Unit of measurement:
Number
Time points
measured: First and
final instruction (visit 1
and visit 3)
Outcome name:
Toothbrushing duration
(behavioural
characteristics)
Outcome definition:
Length of time
toothbrushing
Outcome measure:
Length of time
Outcome measure
validated: NR
Unit of measurement:
Minutes
Time points
measured: First and
final instruction
Results
Notes by review
team
Daily frequency of
toothbrushing: Mean
(SD), P-value
observation period of
this study was
relatively short (3
weeks).
Total sample: NR
Baseline: NR
Follow up (all time
points): NR
End point: NR
Intervention
group(s): n=18
Baseline: 2.11 (0.43)
Follow up (all time
points): N/A
End point: 2.53
(0.40), p<0.01
(Wilcoxon’s signed
rank test)
Control group(s):
n=20
Baseline: 2.13 (0.32)
Follow up (all time
points): N/A
End point: 2.35 (0.81)
Toothbrushing
duration (min):
Mean (SD), P-value
Total sample: NR
Baseline: NR
Follow up (all time
points): NR
End point: NR
It was not possible to
determine whether the
results of this study
could be attributed to
the character of the
intervention or to the
additional time (total of
30 min) spent with
patients in the
intervention group.
This study was
performed only in one
private dental clinic. It
is necessary to
confirm similar results
in other institutions or
clinics in future
research. (p.195)
Self-care behaviour
was only assessed by
means of self-reports.
This method induces
possible bias such as
social desirability,
which might have
influenced outcomes
(p.195).
Limitations identified
231
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
and slight or moderate
periodontitis according
to the previous criteria
of the ADA (2006)
Total sample N = 38
Intervention group N = 18
Control Group N = 20
Exclusion Criteria:
Potential subjects
were excluded if they
had physical
limitations interfering
with manual dexterity,
or fewer than 18 teeth.
Also excluded were
patients who had
undergone extensive
nonsurgical
periodontal treatment
within the previous 6
months, periodontal
surgery within the
previous 2 years or
any active or planned
periodontal treatment
other than routine
dental prophylaxis.
% of selected
individuals agreed to
participate:
NR
Potential sources of
bias:
Self-care behaviour
was only assessed by
Baseline comparisons:
Total group: 16 females and 22
males (there were not
imbalances between the 2
groups: control (8 female, 12
male), intervention (8 female, 10
male))
Study sufficiently powered
(power calculations and
provide details):
A power calculation was
performed to determine the
sample size required. The
standard deviations of
measurement parameters (daily
frequency of toothbrushing)
estimated from the results of a
preliminary study with 10
subjects were 0.28 for the
intervention group and 0.84 for
the control group. A minimum of
30 subjects were required to
allow a 95% chance of detecting
a statistically significant
difference with a set at 0.05 and
the power of the study set at
80%.
Outcome definitions
and method of
analysis
Outcome name:
Weekly frequency of
interdental cleaning
(behaviour
characteristics)
Outcome definition:
Weekly frequency of
interdental cleaning
Outcome measure:
Number of times per
week
Outcome measure
validated: NR
Unit of measurement:
Number
Time points
measured: First and
final instruction
Outcome name: Selfefficacy for brushing of
the teeth
Outcome definition:
Self-efficacy for
brushing of the teeth
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
The answers were
along a 5-point Likert
scale from 1 (not
Results
Notes by review
team
by review team:
Intervention
group(s): n=18
Baseline: 3.38 (0.95)
Follow up (all time
points): N/A
End point: 6.16
(2.20), p< 0.001
(Wilcoxon’s signed
rank test) and p<0.01
(ANCOVA)
Control group(s):
n=20
Baseline: 3.68 (1.73)
Follow up (all time
points): N/A
End point: 4.38
(1.16), p<0.01
(Wilcoxon’s signed
rank test)
Weekly frequency of
interdental cleaning:
Method of participant
recruitment and/or
refusal rate not
reported. Difficult to
understand whether
study population was
representative of
source.
Whether allocation
into groups was
concealed or possible
contamination not
reported.
Effect sizes not
reported.
Evidence gaps:
Total sample: NR
Baseline: NR
Follow up (all time
points): NR
End point: NR
An additional
intervention study is
required to compare
the results between
when six-step method
is carried out by a
dentist and by a dental
hygienist.
Intervention
group(s): n=18
Baseline: 1.22 (1.80)
Follow up (all time
points): N/A
It is necessary to
confirm similar results
in other institutions or
clinics in future
research.
232
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
means of self-reports.
This method induces
possible bias such as
social desirability,
which might have
influenced outcomes
(p.195).
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
confident) to 5
(completely confident)
for each item. A score
of ‘‘Self-efficacy for
brushing of the teeth’’
for each subject was
expressed as the sum
of the scores assigned
for 5 items, therefore
having a range of 5–25
Time points
measured: First and
final instruction
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders):
No drop outs reported.
The Mann–Whitney Utest was used to
analyse differences in
the clinical,
behavioural, and selfefficacy parameters
between the 2 groups
when the subjects start
Step 1 (the first
instruction). Wilcoxon’s
signed-rank test was
Results
End point: 11.56
(4.93) p< 0.001
(Wilcoxon’s signed
rank test) and p<0.01
(ANCOVA)
Control group(s):
n=20
Baseline: 0.85 (1.63)
Follow up (all time
points): N/A
End point: 3.48
(3.11), p<0.01
(Wilcoxon’s signed
rank test)
Notes by review
team
Further studies on the
six-step method are
needed to evaluate
the medium and longterm outcomes,
periodontal status,
compliance for
periodontal treatment
and regular check-ups
(p.195)
Source of funding:
NR
Self-efficacy for
brushing of the teeth:
Total sample: NR
Baseline: NR
Follow up (all time
points): NR
End point: NR
Intervention
group(s): n=18
Baseline: 16.22 (3.23)
Follow up (all time
points): N/A
End point: 22.06
(1.95), p< 0.001
(Wilcoxon’s signed
rank test) and p<0.01
(ANCOVA)
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
performed to examine
significant change
within each group
between the first
instruction and the final
instruction when the
subjects start Step 5 at
the third visit.
The analysis of
covariance (ANCOVA)
was used to test
significant difference in
the behavioural and
self-efficacy parameters
at the final instruction
between the 2 groups
using the parameters at
the first instruction as a
covariate. Multiple
regression analysis was
carried out to test an
association between
toothbrushing
behaviour after
intervention and
possible explanatory
variables (p.194).
Results
Notes by review
team
Control group(s):
n=20
Baseline: 16.55 (3.14)
Follow up (all time
points): N/A
End point: 18.90
(3.04), p<0.01
(Wilcoxon’s signed
rank test)
Attrition details:
NR
Conclusion:
The six-step method
might be more
effective for enhancing
self-efficacy and
behavioural change of
oral hygiene than
traditional oral hygiene
instruction alone. The
six-step method is
suitable for clinical
application because it
is a systematic and
simple method. The
data suggested that
six-step method is a
useful tool for
improving short-term
oral hygiene behaviour
of patients with mild to
moderate
periodontitis.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: Kasila K,
Poskiparta, M, T
Hettunen, T, Pietila,
I
Study design: Data was
collected as part of a larger
project of schoolchild-dental
hygienist communication in
public dental care. Audiotaped
counselling sessions
conducted by dental
hygienists. The follow up data
included 97 counselling
sessions at 2 points in time.
(Paper one, p.421, para.1)
Population the sample
was recruited from:
Public dental care setting
of a single town in Finland.
(Paper One, p.421), (Paper
Two, p108, para.5).
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Paper One
One-sided delivery of
information was occasionally
used within this study.
Individually tailored
information is a necessary
part of counselling. (pp.424,
para.3)
Year: 2006
Citation: Kasila, K.,
Poskiparta, M.,
Kettunen, T. and
Pietila, I. (2006) Oral
health counselling in
changing
schoolchildren’s oral
hygiene habits: a
qualitative study,
Community Dent
Oral Epidemiol, 34,
419-428. (Paper
One)
Kasila, K.,
Poskiparta, M.,
Kettunen, T., and
Pietila, I. 2008,
Variation in
assessing the need
for change of
snacking habits in
schoolchildren’s oral
health counselling,
International Journal
of Paediatric
Data collected was part of a
larger follow-up research
project (2002 – 2005), which
aimed to investigate oral
health counselling of
schoolchildren diagnosed with
at least one active initial
caries lesion by public dental
care. This included 66
counselling sessions in 2002
and 31 counselling sessions
in 2003. The data was
audiotaped. (Paper Two,
p.108, para.5)
Research aims, objectives,
and questions: The aim of
this study was to investigate
schoolchild-dental hygienist
counselling conversations
regarding changes of oral
How sample was
recruited: They were part
of a larger research project
of schoolchild-dental
hygienist communication in
public dental care. (Paper
One, p.421) (Paper Two,
p.108, para.5)
How many participants
recruited: 31 school
children (Paper One,
p.421), (Paper Two, p.109,
para.5).
Sample characteristics:
Age: Between 11 and 13
years old.
Sex: 15 female; 16 male
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Finland
Occupation: NR
The audiotapes from the counselling
sessions were analysed qualitatively
using content analysis. (Paper One,
p.422, para.2)
The children’s individual descriptions of
their oral hygiene habits and dental
hygienists counselling practices were
coded under these 4 study aims:
introduction to counselling, discussion
about assessing the schoolchildren’s
need for change in oral habits,
discussion about readiness for change
and counselling strategies which
considered changes and new oral
hygiene habits. (Paper One, p.422,
para.2)
The counselling conversations about
dietary issues within the counselling
sessions were identified and recorded
in separate files. The analysis then
continued by identifying and labelling
the participants’ communication
activities. The particular phrases,
incidents, turns or types of behaviour
were identified and coded, with due
regard to the schoolchildren’s
In many cases the
assessment of the children’s
readiness for change
remained unclear although
nearly every child had a need
for change in oral hygiene
habits.(p.425, para.1)
Advice was given by using
recommendations and
persuasive styles, both of
which have not shown strong
tendencies to produce
lifestyle change.(pp.426,
para.2)
Could avoid deep
conversation because the
dental hygienist adopted a
dominating role of
professional. Or they were
unaccustomed to
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Dentristy, 18, 107116. (Paper Two)
hygiene habits within the
theoretical framework of the
transtheoretical model and the
motivational interview. (Paper
One, p.421, para.2)
Country of study:
Finland
Quality Score (++,
+, or -): +
The aim of this study was to
explore the counselling
communication activities that
were used for assessing
schoolchildren’s need for
change of snacking habits. In
addition, the schoolchildren’s
assessment of their need for
change was examined one
year later, in 2003. (Paper
Two, p.108, para.5)
Theoretical approach
[grounded theory, IPA etc]:
The transtheoretical model
(Figure 1) and motivational
interviews. (Paper One, p.420,
para.1) (Paper Two, p.108,
para.2).
State how data were
collected:
What method(s):
Paper One
Thirty one 11-13 year old
schoolchildren diagnosed with
at least one initial caries
lesion consented to participate
in an audiotaped counselling
sessions conducted by 4
Population and Sample
Selection
Education: NR
Socioeconomic position:
NR
Social capital: NR
(Paper One, p.421-422),
(Paper Two, p.109,
para.5).
Inclusion criteria: The
school child must have at
least one initial caries
lesion. (Paper One, p.421),
(Paper Two, p.108,
para.5).
Exclusion criteria: NR
Outcomes and Methods of Analysis
Notes by Review Team
individual descriptions of their snacking
habits and the dental hygienists’
communication activities. (Paper Two,
p.110).
participating in conversation
and felt the issues were
difficult or boring. (pp.426,
para.3)
Key themes and findings relevant to
this review [with illustrative quotes
if available]
Public dental care setting
within one town in Finland.
(p.421)
Paper One
 Nearly every school child
needed a change in tooth
brushing practices.
 Their needs for change varied
in different areas (Paper One,
p.423).
 Comparing the children’s selfreport with the
recommendation assessed
their need for improving tooth
brushing frequency. The
children were aware of the
recommendation but needed
to revise the technique used.
This was shown by plaque on
their teeth. 9 children were
advised and guided on
brushing technique. (Paper,
One, p.423, pa2).
 Over two-thirds of the
schoolchildren needed to
change their dental flossing
habits due to at least one
caries lesion and not flossing
regularly. (Paper One, p.423,
para.3).
Took minimal responses
such as “mmm” to mean a
positive acknowledgment but
not necessarily the case with
all participants. (p.422,
para.4)
Schoolchildren stated that
their tooth brushing was
correct although it did not
conform to the
recommendations (p.424,
para.2).
Paper Two
The data were restricted and
therefore cannot be
generalised easily.
The counsellors’ previous
knowledge on counselling
had an effect on driving them
towards a more structure
format.
Limitations identified by
review team:
The dental hygienists and
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
dental hygienists. The child’s
caries lesion was showed to
them using a dental mirror.
Population and Sample
Selection
Outcomes and Methods of Analysis

The follow up data consists of
97 counselling sessions which
formed 2 sequential parts:

In spring 2002 the data
comprised 66 counselling
sessions varying between 1 to
4 per child. These were
completed within one month.
Then in 2003 the data
comprised of 31 counselling
sessions in which the school
children assessed their need
for change in oral hygiene
habits (frequency of
toothbrushing and flossing).
This happened during a single
session.
During the counselling
sessions the hygienist
provided information on the
aetiology of oral diseases, oral
health care and
recommendations. The
hygienist did not encourage
the children to reveal their
own needs, aims, readiness
and expectations of oral
health self-care, changes and
counselling. They stated the
purpose of counselling and
emphasised the importance of
11 schoolchildren were found
to be in preparation to change
their brushing frequency7
school children appeared to be
in preparation for changes in
dental flossing. (Paper One,
p.423, para.5 and para.7).
In 2003 4 children had made
changes, this was related to
the discussion about the
change process and goal
setting. 3 children had made a
change in their dental flossing
habits. 3 children had made
changes in both areas. (Paper
One, p.423, para.7).
Paper Two
The schoolchildren’s snacking habits
were recalled during the counselling
sessions. In 12 of the sessions recall
was very concise and often remained
quite separate from the counselling,
however in 17 the recall was
considerable extended enabling
assessment of snacking behaviour. As
a whole their descriptions of snacking
habits were usually minimal and
ambiguous. (Paper Two, p.110)
The school children’s defensive
attitude was manifested when they
replied to the counsellor’s assessment
by offering excuses for their
detrimental behaviour, such as being
usual for his or her age.
Notes by Review Team
counsellors were not blind to
the research aims and
outcomes.
The research aim,
particularly in Paper One is
quite broad and a series of
more precise objectives
would have enhanced the
clarity of this study.
The sampling strategy is not
set out in Paper One. In
Paper Two it says - "During
regular scheduled
appointments the dental
hygienists systematically
recruited voluntary
schoolchildren who met the
inclusion criterion to
participate in the study"
(Paper Two p.109 para.4)however it is not clear what it
means by "systematic"
Paper Two is clear that the
dental hygienists were the
hygienists the schoolchildren
visited in scheduled
appointments. However there
is no information on how the
research was explained to
participants.
Lack of baseline data
provided.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
their own responsibility for oral
health care. (Paper One,
p.421-422)
Paper Two
The data of a larger follow-up
research project (2002-2005)
comprised 7 counselling
periods that were carried out
at intervals of 6 months. The
number of counselling
sessions varied from one to 4
per schoolchild per period.
The study included 66
counselling sessions in 2002
and 31 counselling sessions
in 2003 with 31 11-13 year old
school children. In 2002 the
sessions were conducted
within one month.
In 2002 the counselling
sessions were selected on the
basis of the aims of the study
being behavioural change.
In 2003 the needs
assessment conversation was
based on a structured
questionnaire which the
schoolchildren were
requested to assess their
need for change of snacking
frequency on a 2-point scale
(true or false). These were
conducted during a single
Population and Sample
Selection
Outcomes and Methods of Analysis
2 major categories also emerged for
the needs assessment practice; these
were schoolchild-determined and
counsellor-determined. For the
counsellor-determined category this
also had subcategories (see Table 1).
(Paper Two, p.110).
The counsellor explicitly determined
and assessed the schoolchildren’s
need for change of snacking habits, in
a few cases there were indications that
the schoolchildren’s perception of need
for change differed from that of the
counsellor. In many cases the
schoolchildren’s needs assessment
remained on the level of the
counsellor’s assessment or advice
after the snacking recall. The form of
advice that was given was usually very
general; more detailed and focussed
advice was rarely provided,
e.g.
General advice: “DH: of course,
thinking about that, you could do
something about that, of course it
would be better, to do something so
that the bacteria wouldn’t get food, you
should try and see how you, how you
eat sweet foods”.
More detailed advice: “DH: You could
now think about it, eating candy,…try
cutting it down a little, have candy as
Notes by Review Team
Only one method and no
information on triangulation.
The authors themselves note
(Paper One p.422 para.4)
that the dental hygienists
may have misinterpreted
some of the participants'
responses (e.g. by assuming
an 'mmm' response to a
question was a positive
acknowledgement).
Limited examples from the
counselling sessions are
provided.
It is not clear whether or not
more than one researcher
looked at the data
Figures are given for
responses in places but
terms like "many" and "a few"
are often used. Extracts of
conversations have been
included and references are
sometimes made to them.
The paper does enhance
understanding of oral health
counselling to a specific
group and in that sense is
relevant and useful for our
study. The authors caution
that their theoretical
approach may not be the
best way to analyse
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
session. (Paper Two, p.109110).
By whom: 4 dental hygienists
(Paper One, p.421-422),
(Paper Two, p.109, para. 4).
What setting: Finland (Paper
One, p.421-422), (Paper Two,
p.108, para. 5)
When: 2002 – 2003. (Paper
One, p.421-422), (Paper Two,
p.109, para. 5).
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
rarely as possible.” (Paper Two, p111)
schoolchild - dental hygienist
oral health practice.
The counsellor also can be seen to be
determining the schoolchild’s need for
change on his behalf “Then how would
you feel if you should try and cut them
down a little”.(Paper Two, p.111)
There are only a few occasions in
which the counsellor encourages the
school child to participate in assessing
the outcomes of the session and
considering the association between
diet and oral health.
In 2003:
 8 schoolchildren had made
positive changes during the
follow-up year and the children
were aware of the need for
change.
 New negative snacking habits
had appeared in 8 children.
 On the whole most of the
children assessed that they
still had a need for change of
snacking habits in 2003.
(Paper Two, p112, para.1 and
2).
Conclusions:
Paper One
The results suggest that the theoretical
framework might be useful in
constructing and focussing on oral
hygiene counselling for school children
that concentrates on the personal
The research received
ethical approval and
informed consent was
obtained from all children,
their guardians and dental
hygienists. However it would
have been useful to have
some information on how
anonymity was maintained
and data was stored.
Quality and usefulness of
Paper Two is better. Study
would not have received as a
high a score on the basis of
Paper One only.
Evidence gaps and/or
recommendations for
future research:
Paper One
Need for improving and
developing oral health
education to meet the
personal needs of the
individual. (Paper One, p,
426, para.5)
Paper Two
Once the counsellors have
been provided with skills to
change their techniques that
this may enable the future
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
dynamics of change. (abstract) The
study revealed how difficult the
practical implementation of counselling
can be. Besides planning the content
the effective practice of health
counselling requires the planning of
communication activity. (Paper One,
p.424, para. 2)
development of more
appropriate and effective
counselling strategies in the
oral health care context.
(p.114, para. 4).
The study showed the how difficult it is
to change an irregular pattern of toothbrushing pattern to a stable and
regular pattern while undergoing the
changes of adolescents.
Barriers to good oral health care were
identified as memory problems, and
the difficulty of finding time as
behavioural changes require time and
energy and are long-term processes.
(Paper One, p.424, para.2).
In this study the session did not reveal
the children’s needs, aims and
readiness for counselling and change
in their oral hygiene habits (Paper One,
p.425, para.1) although their
affirmative responses did seem as if
they were.
Paper Two
The results revealed that a thorough
needs assessment of schoolchildren’s
snacking habits provides a foundation
for behaviourally focussed counselling.
3 issues related to
counselling practice need to
be considered:



Change of time
frame – a lot of focus
on past behaviours
eg what caused the
initial caries.
Salivary lactobacilli
were used but this
did not direct
individualised
counselling.
Regarding the
ambiguous snacking
habits and needs
assessment a
clearer application of
recommendation is
needed to address
the personal level.
(p114-115).
Source of funding:
Acknowledge the financial
assistance of the Ministry of
Social Affairs and Health and
the Finnish Cultural
Foundation. (p.427)
They further reveal that needs
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
assessment of change that involves
schoolchildren in counselling is a
complex and demanding process that
entails a number of concerns.
Changing snaking habits is a difficult
and prolonged process that always
needs to be considered in the
individual and environmental life
context.
Little evidence was shown for the
school children being invited to selfassess their information, however it the
counsellor was speculative that they
did participate.
Often the assessment of the
schoolchildren’s need for change was
counsellor controlled.
In concise answers from children their
personalised and detailed needs
assessment for change remained
incomplete.
Need for mutual assessment before
the change process can begin.
Counsellors need to change their role
from normative and curative to
empowering and participating
approaches. The current style of
counselling is associated with lack of
time, existing professional
predisposition and skills and the child’s
inexperience to participation.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Lees,
A.,Rock, W.P., and
Orth, D
Source
Population(s):
Country of study
(include if developed
or non-developed):
NR – assumed
British
Method of allocation: Sixty-five
subjects who had been fitted
with a lower fixed appliance
during the previous three
months were divided into three
groups by a process of physical
randomisation in which numbers
were drawn from a hat. Every
patient had a similar StraightWire appliance (A Company)
and all brackets were bonded by
the same clinician using Right
On (T.P Company) orthodontic
adhesive.
Oral health outcomes
(clinical):
Oral health (clinical)
results:
Outcome name:
Plaque scores
Outcome definition:
NR
Outcome measure:
Plaque index was
based upon that of
Greene and Vermillion
(1960)
Outcome measure
validated: NR
Unit of measurement:
Plaque was scored for
the five boxes
alongside or gingival to
the bracket to give a
possible maximum
mouth score of 15
Time points
measured: Pre and
post study (8 weeks)
Plaque scores
(Maximum score, Preeducation score [SD],
Post education score
[SD], Percentage
change)
Limitations
identified by author:
In the present study,
subjects in Group 1
and 2 (written and
video respectively)
had access to either
written or video
material during the
whole period of the
study. No attempt was
made to measure the
extent to which either
was used since it
would have been
difficult to do this
reliably, and the whole
objective of the study
was to measure the
effectiveness of three
instructional methods
that were designed to
be used in different
ways.
Year: 2000
Citation: Adele
Lees, W. P. Rock,
and D. Orth., A
Comparison
Between Written,
Verbal, and
Videotape Oral
Hygiene Instruction
for Patients with
Fixed Appliances.
Journal of
Orthodontics, 2000;
27(4): p. 323-328
Aim of Study: The
aims of the present
study were to make
a videotape to teach
oral hygiene to
patients wearing
fixed orthodontic
appliances, and to
test the
effectiveness of
such instruction
against written
instructions and
one-to-one verbal
Setting: UK
[assumed]
Sample
characteristics:
Age: NR
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
Eligible population:
Participants who had
been fitted with a
lower fixed appliance
during the previous 3
months. .
Before the instructions
(described below) the dental
health knowledge of each
subject was tested by means of
a questionnaire which related to
diet and oral health care,
especially in relation to fixed
appliance wear.
Report how confounding
factors were minimised: NR
Programme/Intervention
description:
Written intervention:
Before instruction, each subject
was examined for plaque and
Outcome name:
Gingival index scores
Outcome definition:
NR
Outcome measure:
Gingival index was
based upon that of Loe
and Silness (1963)
Outcome measure
Written
Adjacent to bracket: 6,
5 [1.48], 5 [1.41], 0
Gingival to bracket: 9,
5.14 [2.94], 5.29
[2.72], +2.9
Total buccal: 15, 10.14
[3.66], 10.9 [3.29],
+1.48
Video
Adjacent to bracket: 6,
5.55 [0.86], 5.09
[1.38], -8.29
Gingival to bracket: 9,
6.23 [2.37], 5.23
[2.76], -16.1
Total buccal: 15, 11.77
[2.33], 10.32 [3.33], 12.32
Verbal
Adjacent to bracket: 6,
5.05 [1.46], 4.41
Limitations
identified by review
team:
The setting was not
described at all,
meaning full
replication would be
difficult. The
242
Oral Health: Approaches for general practice teams on promoting oral health
instructions in
improving
knowledge, oral
hygiene standard,
and gingival health.
Study Design: RCT
[Not stated explicitly]
Quality Score (++,
+, or -): +
External
Validity(++, +, or -):
-
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR
Inclusion Criteria:
Participants who had
been fitted with a
lower fixed appliance
during the previous 3
months. Every patient
had a similar StraightWire appliance (A
Company) and all
brackets were bonded
by the same clinician
using Right On (T.P.
Company) orthodontic
adhesive.
Exclusion Criteria:
NR
% of selected
individuals agreed
to participate: NR
Potential sources of
bias: NR
Plaque index was based upon
that of Green and Vermillion
(1960).
validated: NR
Unit of measurement:
Grades of 0-3 denoting
absent, mild, moderate
and severe
inflammation
Time points
measured: Pre and
post study (8 weeks)
Gingival index was based upon
that of Loe and Silness (1963).
Behavioural
outcomes:
Before the instructions
(described below) the dental
health knowledge of each
subject was tested by means of
a questionnaire which related to
diet and oral health care,
especially in relation to fixed
appliance wear.
Outcome name: Oral
health knowledge
Outcome definition:
The dental health
knowledge of each
subject was tested by
means of a
questionnaire which
included open
questions relating to
diet and oral health
care, especially in
relation to fixed
appliance wear.
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Answers were scored
according to an aidememoire prepared
beforehand which listed
20 expected
responses, each of
which was to be
gingival index scoring on the
basis of 3 teeth, lower canine,
lower left central incisor and
lower left first or second
premolar.
Group 1 subjects then received
2 sheets of written information,
specially designed for the study.
There were 6 main sections:
possible problems in the early
stages, appliance care and diet,
plaque disclosure and cleaning,
routine dental care, and
emergency resolution. Ethical
and legal advice was obtained
from the Medical Protection
Society in the preparation of the
text.
Video intervention:
Before instruction, each subject
[1.53], -12.7
Gingival to bracket: 9,
6.14 [2.98], 4.68
[3.32], -23.8
Total buccal: 15, 11.18
[3.63], 9.09 [4.05], 18.7
For the written
instruction group,
scores changed little
over the study period.
Total plaque scores
fell in the other 2
groups (video and
verbal) especially for
plague gingival to the
bracket where
reductions were
around double those
found higher up the
teeth. However,
ANOVA revealed no
significant main
effects or
interactions at p =
0.05, although the
main effect ‘Before
and after instruction’
had p = 0.058, very
close to significance.
description of the
questionnaire and the
concept it actually
measured was
lacking. As was any
reported validity for
the questionnaire. If a
more suitable
outcome measure
was used, there is a
possibility that
favourable effects
would have been
found.
Evidence gaps:
As no significant main
effects or interactions
were found, yet some
results being close to
significance, it would
be beneficial to
explore the effects of
video and verbal
instructions further.
Source of funding:
NR
Gingival Index
Scores (Maximum
score, Pre-education
score [SD], Post
education score [SD],
Percentage change)
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Oral Health: Approaches for general practice teams on promoting oral health
was examined for plaque and
gingival index scoring on the
basis of 3 teeth, lower canine,
lower left central incisor and
lower left first or second
premolar.
mentioned specifically
in the instructions given
to the patient.
Time points
measured: Pre and
post study (8 weeks)
Plaque index was based upon
that of Green and Vermillion
(1960).
Method of analysis
(indicate if ITT or
completer analysis was
used and if
adjustments were
made for any baseline
differences in important
confounders):
Numeric calibration
data were compared
using the Kappa
statistic, whilst ordinal
scores were compared
by means of chisquare. GLM in Minitab
was used for ANOVA
of main study intergroup differences.
Gingival index was based upon
that of Loe and Silness (1963).
Before the instructions
(described below) the dental
health knowledge of each
subject was tested by means of
a questionnaire which related to
diet and oral health care,
especially in relation to fixed
appliance wear.
Group 2 subjects were given a
specially made video film 8
minutes long, which they took
home and kept for the duration
of the study. The title of the film
was Brace Yourself and
included in the introduction were
shots of a theme park ride,
rather like the ‘train-tracks’
analogy applied to fixed
appliances by West Midlands
children. Special effects and
musical backing were also used
to improve the presentation. The
script was based upon
information included on the
Written: 9, 2.05 [1.86],
2.62 [1.96], +27.8
Video: 9, 2.32 [1.76],
1.91 [2.2], -17.68
Verbal: 9, 2.73 [2.43],
2.14 [1.58], -22.62
Gingival index scores
increased by 28% in
the written instruction
group and fell in the
other 2 groups.
ANOVA showed no
main effects or
interactions.
Behavioural results:
Questionnaire
(Maximum score, Preeducation score [SD],
Post education score
[SD], Percentage
change)
Written: 20, 7.93
[2.65], 7.36 [3.35], -7.2
Video: 20, 7.84 [2.41],
9.23 [1.39], +17.2
Verbal: 20, 6.8 [3.1],
8.34 [3.00], +22.6
No increase above
was significant
244
Oral Health: Approaches for general practice teams on promoting oral health
written information sheets. Still
frames from the video are
shown as Figures 2–4
Verbal Intervention:
Before instruction, each subject
was examined for plaque and
gingival index scoring on the
basis of 3 teeth, lower canine,
lower left central incisor and
lower left first or second
premolar.
Plaque index was based upon
that of Green and Vermillion
(1960).
Gingival index was based upon
that of Loe and Silness (1963).
Attrition details:
Indicate the number
lost to follow up and
whether the proportion
lost to follow-up
differed by group (i.e.
intervention vs
control): NR
Conclusion:
Analysis of variance
revealed no significant
main effects or
interactions at p =
0.05, although the
difference in the
plaque index scores
before and after
instruction was close
to significance.
Before the instructions
(described below) the dental
health knowledge of each
subject was tested by means of
a questionnaire which related to
diet and oral health care,
especially in relation to fixed
appliance wear.
Group 3 subjects were each
seen by a dental hygienist on
one occasion who gave oral
health advice according to
written instructions based upon
those given to the Group 1
subjects. The visit was timed to
last 30 minutes. Several
hygienists took part in the study
245
Oral Health: Approaches for general practice teams on promoting oral health
and to help the consistency of
advice given to the subjects all
of the hygienists had read the
written instructions and watched
the video.
Sample size at baseline:
Total sample N = 65
Written Intervention Group N
= 21
Video Intervention Group N =
22
Verbal Intervention Group N =
22
Baseline comparisons (report
any baseline differences
between groups in important
confounders): NR
Study sufficiently powered
(power calculations and provide
details): NR
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Lepore, L.
et al
Source
Population(s):
Unclear: Although
study was approved
by Columbia
University (New
York) – so probably
the US
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): Unclear – only says
‘participants were divided
randomly into control and
intervention groups’.
It is unclear what the
unit of measurement is
for clinical outcomes could be score of 0, 1,
2 (Score of 0 (low), 1
(moderate) or 2 (high)
caries risk) as it is for
the behavioural
outcomes
Oral health (clinical)
results:
Limitations identified
by author:
S. mutans:
Report how confounding
factors were minimised: NR
Outcomes:
There was disparity in
the control and
intervention groups at
initial examination in
the areas of plaque
score and S. mutans
level. Pearson chi
squared analysis
revealed that the
intervention group had
significantly higher S.
mutans level and
plaque score
averages at the initial
visit. However, since
this study is evaluating
the improvement of
the oral health
measures, the change
noted within the
groups between the
initial and follow-up
visits is still statistically
significant.
Year: 2011
Citation: Lepore,
L., Yoon, R.K.,
Chinn, C.H., and S.
Chussid. Evaluation
of Behaviour
Change GoalSetting Action Plan
on Oral Health
Activity and Status.
New York State
Dental Journal.
2011. 77; 6;43-48
Country of study:
NR
Aim of Study: The
aim of the study
was to determine if
a “report card-like”
oral health action
plan was effective in
improving oral
health behaviours in
a sample of patients
aged 1 to 6 years.
Exploring: 1.
Whether it is
Setting: Clinical
(unclear)
Location (urban or
rural): NR
Sample
characteristics:
Age: 1 – 6 years.
Mean age of 3 years
and 90% were 2 to 5
years.
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation:
Children
Education: NR
Socioeconomic
position: NR
Social capital: NR
Programme/Intervention
description:
What was delivered: Patients
received intraoral and extraoral
examinations, a dental prophylaxis
and a topical fluoride application
by one trained dentist examiner.
Examination data collected
included DMFS, gingival health
and plaque scores.
Clinical:
Outcome name: S.
mutans
Outcome measure:
Exam
Outcome measure
validated: NR
Time points
measured: Pre and
post intervention (start
and end point)
Parents were questioned
regarding the oral hygiene and
diet behaviour of the child in order
to fulfil the six survey topics
(frequency of toothbrushing with a
fluoridated dentifrice, parentassisted toothbrushing, bottle use,
sippy cup use, frequency of juice
consumption and frequency
between-meal snacking)
Outcome name:
Plaque score
Outcome measure:
Exam
Outcome measure
validated: NR
Time points
measured: Pre and
post intervention (start
and end point)
Intervention
group(s):
Baseline: 0.700
End point: 0.540
Change: 0.432
p value: 0.000
Control group(s)
Baseline: 0.660
End point: 0.690
Change: -0.031
p value: 0.745
Plaque score:
Intervention
group(s):
Baseline: 1.080
End point: 0.110
Change: 0.973
p value: 0.000
Control group(s)
Baseline: 0.660
End point: 0.560
Change: 0.094
p value: 0.184
Sample size: a larger
sample size would
allow for better
randomisation and
more equivalent
sample groups.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
feasible for
clinicians to engage
parents of patients
with ECC risk
factors in
collaborative goalsetting and concrete
action planning
during the initial
dental evaluation
visit, and 2.
Determining the
effectiveness of a
personalised
detailed oral health
action plan in
improving parentpatient oral health
behaviours and oral
health status of the
child.
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g.
media
advertisement,
class list, area):
Paediatric-child
patients (unclear how
recruited to study)
Patients in both groups received
routine, verbally dispensed oral
hygiene and diet instructions
targeting the specific needs of the
patient. In addition they received a
personalised oral health action
plan (Figure 1). The action plan
consisted of an assessment of the
patient’s current caries risk and a
list of suggestions on how to
improve that status. The parent
and dentist together chose one
particular suggestion they felt was
achievable.
Outcome name: dmft
Outcome measure:
Exam
Outcome measure
validated: NR
Time points
measured: Pre and
post intervention (start
and end point)
dmft:
State if eligible
population is
considered by the
study authors as
representative of
the source
population: NR
Study Design:
Quasi-experimental
design. Participants
were divided
randomly into
control and
intervention groups.
Inclusion Criteria:
Paediatric-child
patients aged
between 1 and 6
Quality Score (++,
+, or -): -
% of selected
individuals agreed
to participate: NR
External
Validity(++, +, or -):
-
Exclusion Criteria:
NR
Potential sources of
bias: Potential
Patients returned after 2 months
and again received a dental
examination and parental survey
regarding oral hygiene and diet.
Theoretical basis: No
By whom: Examinations = trained
dentist examiner, Intervention =
Dentist
To whom: Parent and child
How delivered: Verbal
instructions and visual oral health
action plan
When/where: Clinic
How often: Examination at
baseline visit and follow up 2
months later. Intervention at
baseline
How long for: Follow up after 2
months
Outcome name:
Gingival health
Outcome measure:
Exam
Outcome measure
validated: NR
Time points
measured: Pre and
post intervention (start
and end point)
Behavioural:
Outcome name: No.
times brushing per day
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Score of 0 (low), 1
(moderate) or 2 (high)
caries risk
Time points
measured: Pre and
Intervention
group(s):
Baseline: 1.320
End point: 1.320
Change: 0.000
p value: Control group(s)
Baseline: 0.440
End point: 0.440
Change: 0.000
p value: -
Notes by review
team
Observation time:
Increasing the
observation time to a
six-month follow-up
may have resulted in a
more complete study.
Potential examiner
bias: Since this was a
single blind study,
upon follow-up
examination
experimenter bias has
to be considered and
results may be
skewed.
Gingival health:
Intervention
group(s):
Baseline: 0.590
End point: 0.140
Change: 0.459
p value: 0.000
Control group(s)
Baseline: 0.500
End point: 0.500
Change: 0.000
p value: 1.000
Behavioural results:
No. brushing/day:
Limitations identified
by review team:
Source population not
well described –
unclear whether the
eligible population is
representative of the
source population.
Randomisation
process not clear – a
quasi-experimental
design, but
participants were
randomised.
248
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
examiner bias: Since
this was a single
blind study, upon
follow-up
examination
experimenter bias
has to be considered
and results may be
skewed.
Control/Comparator
description:
What was delivered: Patients
received intraoral and extraoral
examinations, a dental prophylaxis
and a topical fluoride application
by one trained dentist examiner.
Examination data collected
included DMFS, gingival health
and plaque scores.
Parents were questioned
regarding the oral hygiene and
diet behaviour of the child in order
to fulfil the 6 survey topics
(frequency of toothbrushing with a
fluoridated dentifrice, parentassisted toothbrushing, bottle use,
sippy cup use, frequency of juice
consumption and frequency
between-meal snacking)
Patients in both groups received
routine, verbally dispensed oral
hygiene and diet instructions
targeting the specific needs of the
patient.
Patients returned after 2 months
and again received a dental
examination and parental survey
regarding oral hygiene and diet.
By whom: Trained dentist
examiner and dentist
To whom: Parent and child
How delivered: Verbally
Outcome definitions
and method of
analysis
post intervention (start
and end point)
Outcome name: Who
brushes
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Score of 0 (low), 1
(moderate) or 2 (high)
caries risk
Time points
measured: Pre and
post intervention (start
and end point)
Outcome name: Bottle
use
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Score of 0 (low), 1
(moderate) or 2 (high)
caries risk
Time points
measured: Pre and
post intervention (start
and end point)
Outcome name: Sippy
cup use
Outcome measure:
Results
Notes by review
team
Intervention
group(s):
Baseline: 0.730
End point: 0.000
Change: 0.730
p value: 0.000
Evidence gaps:
It is hoped the results
of this pilot study will
promote the
completion of similar,
larger studies focusing
on the use of goalsetting action planning
in the dental office.
Control group(s)
Baseline: 0.690
End point: 0.060
Change: 0.625
p value: 0.000
Source of funding:
NR
Who brushes:
Intervention
group(s):
Baseline: 0.950
End point: 0.050
Change: 0.892
p value: 0.000
Control group(s)
Baseline: 1.000
End point: 0.190
Change: 0.813
p value: 0.000
Bottle Use:
Intervention
group(s):
Baseline: 0.570
End point: 0.030
Change: 0.541
p value: 0.000
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
When/where: Clinic
How often: Baseline visit and
follow up 2 months later.
How long for: Follow up after 2
months
Sample size at baseline:
Total sample N = 69
Intervention group N = 37
Control Group N = 32
Baseline comparisons (report
any baseline differences
between groups in important
confounders): NR
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of
analysis
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Score of 0 (low), 1
(moderate) or 2 (high)
caries risk
Time points
measured: Pre and
post intervention (start
and end point)
Outcome name: No.
juice/day
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Score of 0 (low), 1
(moderate) or 2 (high)
caries risk
Time points
measured: Pre and
post intervention (start
and end point)
Outcome name: No.
snacks/day
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Score of 0 (low), 1
Results
Notes by review
team
Control group(s)
Baseline: 0.250
End point: 0.000
Change: 0.250
p value: 0.018
Sippy cup use:
Intervention
group(s):
Baseline: 0.540
End point: 0.080
Change: 0.459
p value: 0.000
Control group(s)
Baseline: 0.220
End point: 0.000
Change: 0.219
p value: 0.006
No. juice/day:
Intervention
group(s):
Baseline: 0.730
End point: 0.110
Change: 0.622
p value: 0.000
Control group(s)
Baseline: 0.530
End point: 0.090
Change: 0.438
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
(moderate) or 2 (high)
caries risk
Time points
measured: Pre and
post intervention (start
and end point)
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any
baseline differences
in important
confounders):
ITT - NR
Data collected at the
initial and follow-up
visits were compared
and analysed using a
paired t-test and
Pearson chi square
analysis.
Results
Notes by review
team
p value: 0.000
No. snacks/day:
Intervention
group(s):
Baseline: 0.300
End point: 0.030
Change: 0.270
p value: 0.006
Control group(s)
Baseline: 0.250
End point: 0.030
Change: 0.219
p value: 0.006
Attrition details: NR
Conclusion:
Collaborative goalsetting between
clinicians and parents
of child patients for
improved health
behaviours is viewed
favourably by parents
and has a positive
impact on clinical
outcomes, evidenced
by a decrease in
plaque and gingivitis
and S mutans counts.
Considering this,
behaviour change
goal-setting action
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
plans may be a
promising technique
for assisting parents
in improving child oral
health status and
behaviours.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author:
Levesque, M, C.
et al
Study design: Qualitative
research based on open-ended
interview questions, which were
videotaped (1045, para.4).
“service-user” action research
(p.1051, para.6)
Population the sample
was recruited from:
Individuals in Montreal,
living on or having
experienced welfare.
Brief description of method and
process of analysis [including analytic
and data collection technique]:
Limitations identified by
author:
Year: 2009
Citation:
Lévesque, M.C.,
et al., Bridging
the poverty gap
in dental
education: how
can people living
in poverty help
us? Journal Of
Dental
Education, 2009.
73(9): p. 10431054.
Country of
study: Canada
Quality Score
(++, +, or -): +
Research aims, objectives, and
questions: The article describes
an original tool designed to
develop dental care providers’
knowledge and enhance their
competence in interacting with
people living in poverty. As well,
it describes the collaborative
methodology that was employed
to create this educational
experience in Montreal, Canada.
Theoretical approach
[grounded theory, IPA etc]: NR
State how data were collected:
What method(s): Following
discussions during a 2006
Montreal-based colloquium on
access to dental care, mutual
concern for the status of relations
between dental professionals
and people on welfare led to a
partnership among
representatives of 4 sectors of
society: public health
researchers, oral health
professionals, underprivileged
populations, and the city’s public
How sample was
recruited:
Four workshops took place
over the course of a year
(November 2006–October
2007), in between which
substantive project
activities unfolded. DVD
participant recruitment,
interviewing, and filming
began following the first
workshop and continued
for approximately 6 months
(January–June 2007).
Individuals living on
welfare or having
experienced welfare were
approached in Montreal,
and attempts were made
to engage people with
diverse profiles in terms of
age, gender, and marital
status. Most of these
individuals were known to
the project’s public health
agency partner through her
involvement in community
organisations. A few
people approached were
identified via personal
A near final cut of the edited video
underwent a series of pretests via
presentation to informal gatherings of
small groups of dental hygienists (n=5)
and dental students (n=3). 4 dentists also
viewed and gave feedback on the video.
Feedback was obtained in person from 2
of the dentists. The video was mailed to
the other 2 dentists, who mailed back
their comments. The feedback obtained,
much of which was positive, was
presented and discussed in the fourth
workshop. This process led to some final
editorial changes and, most significantly,
to a consensus on the need for additional
accompanying information in the form of
a viewing guide, which is presently under
development. The final edition of the
thematically organised video was viewed
by all 6 interviewees, who approved the
content and signed an agreement for its
use for educational purposes and with
health professionals in various settings.
Also, a viewing session was organised by
the province of Quebec Anti-Poverty
Coalition with a group of 8 persons living
on welfare not directly involved in the
project. The group unanimously identified
with the perspectives and experiences
related by the 6 individuals featured.
Limitations not discussed
but some challenges of the
research are referred to:
…the collaborative
approach is not without
challenge. It is at times
complex and even
complicated as it supposes
the establishment and
upkeep of many
relationships based on
trust, respect, and ongoing
communication (p.1052,
para.2).
Limitations identified by
review team:
Not all sections of the
findings are directly
relevant to this review. The
paper does discuss
barriers and facilitators to
accessing oral health/
education but some of the
findings are about being on
welfare more generally and
not directly related oral
health promotion.
Study aims and objectives
are not clearly set out in
the paper.
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Study Details
Research Parameters
health agency. In the fall of 2006,
10 individuals representing these
4 sectors began collaborating on
the “Listening to Each Other”
knowledge translation project
(see Table 1). The purpose of
this group was to develop a DVD
to provide a means for people
living on welfare—given their
particular vulnerability to societal
prejudices and very low
socioeconomic position—to voice
their opinions, perceptions, and
experiences related to poverty
and oral health.
The decision to gather video
testimony from people living on
welfare was founded on the
assumption that access to the
insider perspective might
contribute compelling and
socially valid knowledge directly
linked to the practice of dentistry.
Population and Sample
Selection
acquaintances of one of
the researchers.
How many participants
recruited: 6 participants
provided consent to be
filmed (2 of whom were
also project partners)
Sample characteristics:
Age: NR
Sex: 4 females, 2 males
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Montreal
Occupation:
Education: NR
Socioeconomic position:
very low
Social capital: NR
Inclusion criteria: NR
Pre-interviews were conducted in
which these collaborators shared
information about their lives in
general, their oral health, and
their relationships with dental
professionals.
Once the participants who
agreed to be filmed were
recruited (6 in total), open-ended
interview questions were then
developed. These interview
questions were based on the
Exclusion criteria: NR
Outcomes and Methods of Analysis
Notes by Review Team
Key themes and findings relevant to
this review [with illustrative quotes if
available]
Only one method used
(interviews)
The importance of Teeth and Oral
Health:
- Some participants stated their
preference for keeping their
natural teeth – even at the cost
of pain – and avoiding extraction
and prosthetics
- Other participants made light of
tooth loss and expressed that
access to root canals and other
sophisticated forms of
intervention remain in the realm
of the socioeconomically
advantaged.
“Years of bad life…rough on your
teeth… They’re the first to go
when you lead a bad life”
Relationships with Oral Health
Professionals:
- Empathy: one interviewee stated
that they confide in the dentist or
doctor when things go wrong but
also highlighted the deleterious
effect that a lack of empathy or
perceived prejudice could have
on her inclination to disclose
information related to her oral
health and overall well-being.
- The front desk: “I was always
treated normally. But I find it
embarrassing (being on welfare)”
Short conclusion and there
is no reference to
limitations of the study.
Evidence gaps and/or
recommendations for
future research:
NR
Source of funding:
This project was funded by
the Fonds de la recherche
en santé du Québec
(FRSQ)–Réseau de
recherche en santé
buccodentaire et osseuse
(RSBO). This project is
currently funded by the
Quebec MDEIE.
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Study Details
Research Parameters
participants’ experiences and
perceptions as well as the
themes identified in the
workshops.
Population and Sample
Selection
Outcomes and Methods of Analysis
-
By whom:
Group members:
3 experts on poverty:
-province of Quebec Anti-Poverty
Coalition representatives (2)
-former welfare recipient (1)
-
4 academics/researchers:
-McGill University Faculty of
Dentistry (3)
-University of Montreal Faculty of
Dentistry (1)
1 Public Health Agency
representative:
-Montreal-Center Public Health
Agency (1)
2 professional orders in dentistry:
-Quebec Order of Dentists (1)
-Quebec Order of Dental
Hygienists (1)
What setting: Interviewees were
interviewed in a location chosen
by them (where these locations
are not reported).
When: (First workshops Nov
2006 – Oct 2007). DVD filming
began after the first workshop
and continued for approx. 6
months (Jan – June 2007).
-
-
Notes by Review Team
Discretion: general agreement
that patients should be treated
confidentially when dealing with
participants on welfare
But expectations for discretion, a
positive front desk and empathy
did not occur in the testimony of
all 6 participants.
Interviewees also expressed the
importance of communication
and being involved in their
treatment decision making. It
was pointed out that dental
health professionals should not
automatically assume that
someone on welfare cannot afford a more expensive
intervention, as some patients
may be willing to borrow money
for treatment. “When the time
came to repair a broken filling, he
didn’t ask me my opinion. He
decided, as he was injecting me,
to use an amalgam. It was
difficult to talk and tell him I
wanted a composite. . . . I would
have liked for him to ask me
what I wanted.”
When asked what she most
wanted dental professionals to
know about people who receive
welfare, a participant simply
stated: “Just don’t forget, the
person before you may have
been a worker before becoming
a welfare recipient.”
It appears that, in general, most
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
interviewees consider the view
dental professionals and staff
hold of them to be important and
that this view inspires or taints
the valued dimensions of
empathy, reception,
communication, and discretion.
Barriers to Accessing Dental Services:
- Dental insurance: the
interviewees lamented both
limitations and delays in
coverage offered and how these
impact their behaviours. “You
know, dental care is covered
when you’re on welfare, but only
after you’ve been on it for at least
6 months,”
- Fear of limited coverage:
“Nowadays I’m afraid of going to
the dentist and of finding out that
something is wrong, that I need
some work that is not covered . .
. and that I’ll be faced with the
decision: do I borrow to pay for
the treatment, or do I just put up
with the problem . . . ?...”
- Transportation: highlighted as a
financial and organisational issue
for individuals living outside
densely populated urban areas.
- Barriers in accessing information
on dental coverage and clinics:
“… ‘Is this covered on welfare? Is
this treatment paid for?’ . . .
There is nowhere I can go to
check on what exactly is covered
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
by the welfare programme. And I
find it embarrassing to ask.”
Other results (not relating to oral health):
Everyday Life on Welfare:
- Social isolation: interviewees
commented on their inability to
keep up with social standards.
One participant expressed:
“Sometimes there are activities I
don’t do because I don’t want
people to ask me: ‘So what do
you work in?’ because I presently
don’t work.”
- Shame: Several interviewees
explained how their own
preconceptions towards people
on welfare compound the shame
they feel when others look down
on them, whether at the welfare
agency office or among
community acquaintances.
- Pride: interviewees expressed
positive feelings when talking
about things in their life of which
they are proud.
Poverty pathways:
- Circumstances that led the
individual to be on welfare:
combination of burnout, disease,
single parenting, separation,
depression, and job loss.
- Complexity of personal
characteristics highlighted…
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Conclusions:
Reducing the burden of oral health
disease in socioeconomically
disadvantaged populations will require
solutions that address the many
complexities of the access to care
challenge. Through the development of
an educational tool for improving
knowledge and increasing dental
professionals’ competence in interacting
effectively with the underprivileged, this
project contributes a promising approach
to addressing the relational dimension of
the problem.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Little SJ
Hollis JF, Stevens
VJ, Mount K,
Mullooly JP,
Johnson BD
Source
Population(s):
Male and female
patients between the
ages of 50 and 70
year with mild to
moderate periodontal
disease were the
target population.
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): NR
Outcomes (include
details of all relevant
outcome measures
and whether
measures are
objective or subjective
or otherwise
validated):
For each outcome report
Means, SDs, p-values,
CIs, Effect sizes, SEs
Limitations
identified by
author:
The limitations of this
study include its
focus on older,
volunteer periodontal
patients who may
have been more
motivated than the
general population. It
remains to be
determined if this
group intervention
would be effective for
other age groups and
delivery settings.
Year: 1997
Citation: Little, S.J.,
et al. Effective
group behavioural
intervention for
older periodontal
patients. Journal of
periodontal
research, 1997. 32,
315-25.
Country of study:
USA (developed
country)
Aim of Study:
Assess the effect of
a group-based
behaviour
modification
intervention on oral
hygiene skills,
adherence and
clinical outcomes for
older periodontal
patients.
Setting: This study
was conducted in the
Kaiser Permanente
Dental Care Program
(KPDCP), a dental
HMO currently
providing
comprehensive oral
health care to 150,000
members in 12 large
dental clinics in
northwest Oregon and
southwest
Washington, USA.
Location (urban or
rural): NR
Sample
characteristics:
Age: Mean age of
both control and
intervention groups
was 56.9
Report how confounding
factors were minimised:
Contamination effects not
reported. No statistically
significant baseline differences
were found.
Programme/Intervention
description:
What was delivered: The
intervention consisted of five
90 minute oral hygiene classes
called Freedom from Plaque
(FFP). The sessions included:
bleeding points feedback
followed by group meetings,
where participants discussed
their difficulties, setbacks and
successes, received oral
hygiene skills training and were
helped to develop behaviour
change strategies.
Theoretical basis: Testing the
theory that group-based oral
hygiene intervention can be
Outcome name:
Plaque
Outcome definition:
Plaque was scored as
present or absent
after disclosing using
an adaptation of the
Poshadley Haley
Plaque Index.
Outcome measure:
Dichotomous: present
or absent (%)
Outcome measure
validated: NR
Unit of
measurement: %
Time points
measured: Baseline
and four month followup
Outcome name:
Gingival bleeding
Outcome definition:
Gingival bleeding was
recorded using the
Oral health (clinical)
results:
Outcome: Plaque (whole
mouth)
Intervention group(s):
Baseline (whole mouth):
82%
End point (whole mouth):
76%
Baseline (<3mm): 79%
End point (<3mm): 71%
Baseline (3-6mm): 94%
End point (3-6mm): 89%
Baseline (>6mm): 93%
End point (>6mm): 92%
Control group(s)
Baseline (whole mouth):
80%
End point (whole mouth):
80%
Baseline (<3mm): 75%
End point (<3mm): 76%
Baseline (3-6mm): 93%
End point (3-6mm): 92%
Baseline (>6mm): 96%
End point (>6mm): 99%
Limitations
identified by review
team: Article quotes
number of members
and their location but
there is no
information on
population
demographics. This
could be an issue as
the "members" are
likely to be people
with a higher income
who can access oral
healthcare. There
may be also sources
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Study Design:
Parallel RCT –
follow up data were
collected for both
groups 4 months
after randomisation.
Sex: 50% of the
intervention group and
34% of the control
group were female.
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
northwest Oregon and
southwest
Washington, USA
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
more effective than individual
approaches. Group
intervention allows more
efficient use of interventionists’
time and has the benefit of the
normative power inherent in
small peer-group settings.
Applied the principles of
behavioural self-management.
Quality Score (++,
+, or -): - (3 of the
questions scored
NR while the
average of the
remaining 3
questions was +)
External
Validity(++, +, or -):
++
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): Target
population between 50
and 70 years old. Final
eligibility requirements
included having at
least 6 sites with
periodontal pockets
between 4 and 7 mm
and evidence of
bleeding upon probing
By whom: Dental Hygienist
delivered bleeding points
feedback but it’s not clear who
delivered group education
classes.
To whom:54 participants
How delivered: Group
sessions.
When/where: Evening, with
transport offered for those who
needed it.
How often: NR
How long for: 90 minutes
each
Control/Comparator
description:
What was delivered: Usual
dental treatment
By whom: N/A
To whom: 53 participants
How delivered: N/A
When/where: N/A
How often: N/A
Outcome definitions
and method of
analysis
Loe and Silness
Gingival Index but
scored as “no
bleeding” or
“bleeding” after
skimming with slight
lateral pressure along
the upper 2 mm of the
sulcus with a
periodontal probe.
Outcome measure:
Dichotomous: “no
bleeding” or
“bleeding” (%)
Outcome measure
validated: NR
Unit of
measurement: %
Time points
measured: Baseline
and 4 month follow-up
Outcome name:
Bleeding on Probing
Outcome definition:
Scored as “no
bleeding” or
“bleeding” after
skimming with slight
lateral pressure along
the upper 2 mm of the
sulcus with a
periodontal probe Outcome measure:
Dichotomous: “no
bleeding” or
Results
Notes by review
team
Net change scores
(change in intervention
group minus change in
control group – positive
score indicates greater
improvement in
intervention group or less
of a decline):
Whole mouth – 7
percentage points (pp.)
p=0.002
< 3mm – 8 pp p=0.001
3-6mm – 5pp p=0.062
>6mm – 3pp p=0.546
of bias in terms of
ethnicity.
Outcome: Gingival
bleeding
The method of
selection is well
described and the
inclusion and
exclusion criteria are
explicit. However
there is no
information
comparing the
characteristics of
those who agreed to
participate and those
who did not, to judge
whether any bias
exists.
Intervention group(s):
Baseline (whole mouth):
9%
End point (whole mouth):
4%
Baseline (<3mm): 7%
End point (<3mm): 3%
Baseline (3-6mm): 14%
End point (3-6mm): 7%
Baseline (>6mm): 13%
End point (>6mm): 0%
The dental hygiene
rater, who assessed
all the clinical and
skills assessment
measures at baseline
and follow-up, was
blind to group
assignment.
However there is no
information on
participant blinding.
Control group(s)
Baseline (whole mouth):
10%
End point (whole mouth):
10%
It is not clear whether
any members of the
intervention and
control groups went
to the same dental
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Study details
Population and
setting
Method of allocation to
intervention/control
and/or gingival
inflammation.
How long for: N/A
Sample size at baseline:
State if eligible
population is
considered by the
study authors as
representative of the
source population:
Not reported. The
population was drawn
from KPDCP
members and there is
no information on their
demographics. As
mentioned it could be
that certain socioeconomic or ethnic
groups may be underrepresented.
Inclusion Criteria:
Not reported
separately to eligible
population.
Exclusion Criteria:
Potential subjects
were excluded if they
had physical
limitations interfering
with manual dexterity,
fewer than 18 teeth,
Total sample N = 107
Intervention group N = 54
Control Group N = 43
Baseline comparisons (report
any baseline differences
between groups in important
confounders): The treatment
groups did not differ
significantly at baseline in
mean age, smoking status,
dental care utilisation, selfreported flossing and flossing
skills.
Study sufficiently powered
(power calculations and
provide details): Overall power
not reported. Pocket depth and
attachment loss were
considered secondary outcome
measures due to the lack of
power to detect significant
changes. For the other clinical
outcomes the paper states that
because the number of sites in
the >6mm categories was
small power was extremely
limited.
Outcome definitions
and method of
analysis
“bleeding” (%)
Outcome measure
validated: NR
Unit of
measurement: %
Time points
measured: Baseline
and 4 month follow-up
Outcome name:
Pocket depth
Outcome definition:
Not clear
Outcome measure:
Pocket depth and
attachment loss were
measured with the
Florida probe system,
an electronic,
pressure-sensitive
probe. Bleeding after
probing for pocket
depth was recorded
when haemorrhaging
was present after
probing each
quadrant for the first
time.
Outcome measure
validated: NR
Unit of
measurement: mm
Time points
measured: Baseline
and 4 month follow-up
Results
Notes by review
team
Baseline (<3mm): 9%
End point (<3mm): 8%
Baseline (3-6mm): 15%
End point (3-6mm): 14%
Baseline (>6mm): 19%
End point (>6mm): 15%
clinic so
contamination is a
possibility.
Net change scores
(change in intervention
group minus change in
control group – positive
score indicates greater
improvement in
intervention group or less
of a decline):
Whole mouth – 5
percentage points (pp.)
p=0.001
< 3mm – 4 pp p=0.001
3-6mm – 7pp p=0.008
>6mm – 9pp p=0.464
Outcome: Bleeding on
probing
Intervention group(s):
Baseline (whole mouth):
24%
End point (whole mouth):
15%
Baseline (<3mm): 16%
End point (<3mm): 11%
Baseline (3-6mm): 50%
End point (3-6mm): 29%
Baseline (>6mm): 83%
The study goal was
to test a group based
behavioural
intervention model delivered through 5
90 minute sessions.
However prior to
attending each
session members of
the intervention
group had their
bleeding points
assessed by a
hygienist who then
helped the patient
learn how to clean
specific problem
areas. This support
was not provided to
members of the
control group who
received only the
usual dental
treatment.
Consequently it is
possible that relative
improvement in oral
health amongst the
intervention group
may in part reflect
these measures
rather than the group
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Study details
Population and
setting
hepatitis B, diabetes
mellitus or
immunodeficiency, or
if they were taking
medications known to
affect inflammation of
gingival tissues, such
as phenytoin,
antisialogogue
medicaments,
steroids, hormone
medications or
required prophylactic
antibiotic
premedication.
Also excluded were
patients who had
extensive non-surgical
periodontal treatment
within the previous 6
months, periodontal
surgery within the
previous 2 years or
any active or planned
periodontal treatment
other than routine
dental prophylaxis.
% of selected
individuals agreed to
participate: 56%
(470) of 829 selected
participants agreed to
come in for further
screening. Of those
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Outcome name:
Attachment loss
Outcome definition:
Not clear
Outcome measure:
Pocket depth and
attachment loss were
measured with the
Florida probe system,
an electronic,
pressure-sensitive
probe. Attachment
loss measurements
were repeated on all
high-risk and
Ramjford Index teeth.
If the first and second
measures differed 1
mm or more, a third
pass was taken and
the mean of the
closest 2 measures
was used as the
score.
Outcome measure
validated: NR
Unit of
measurement: mm
Time points
measured: Baseline
and 4 month follow-up
Outcome name:
Flossing skills
Outcome definition:
Flossing criteria
Results
Notes by review
team
End point (>6mm): 50%
sessions.
Control group(s)
Baseline (whole mouth):
26%
End point (whole mouth):
21%
Baseline (<3mm): 17%
End point (<3mm): 16%
Baseline (3-6mm): 50%
End point (3-6mm): 36%
Baseline (>6mm): 91%
End point (>6mm): 69%
In terms of validation,
most outcome
measures were
clinical, objective and
based on existing
indexes (e.g. plaque
scores). The flossing
and brushing skills
index, which was
used by the dental
hygiene rater, was
assessed using a
one week test-retest
intra-rater reliability
test. However,
possibly due the testretest sample being
highly educated, 8690% of the scores fell
in the highest range
of the 3 brushing
index components so
there was insufficient
variation to obtain a
stable estimate of
intra-class
correlation. Patient
reported outcomes
were also used and
do not appear to
have been validated.
Net change scores
(change in intervention
group minus change in
control group – positive
score indicates greater
improvement in
intervention group or less
of a decline):
Whole mouth – 5
percentage points (pp.)
p=0.009
< 3mm – 8 pp p=0.009
3-6mm – 5pp p=0.059
>6mm – 3pp p=0.437
Outcome: Pocket depth
(mm) – mean scores
Intervention group(s):
Baseline (whole mouth):
2.47mm
No effect sizes are
given from the results
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Study details
Population and
setting
interested in
participating, 48%
(226) were ineligible
after further
questioning about
dental history or
availability for classes
and the remaining
52% (244) attended a
clinical screening visit.
Of these 244, 44%
(107) met final
eligibility requirements
(p. 317 para.2).
Potential sources of
bias:
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
included flossing
beneath the gumline,
wrapping floss “C”
style around the
interproximal surface,
and using at least 2
up and down
interproximal strokes.
Outcome measure:
Patients scored 2 for
demonstrating the
criteria on all teeth
observed in the arch,
1 for demonstrating
the criteria on at least
one-half of the teeth
observed in the arch,
and 0 for anything
else. The total index
score possible was 12
points each for
brushing and flossing
Outcome measure
validated: NR
Unit of
measurement: Index
score.
Time points
measured: Baseline
and 4 month follow-up
Outcome name:
Brushing skills
Outcome definition:
Brushing criteria
included brushing the
Results
Notes by review
team
End point (whole mouth):
2.43mm
Baseline (<3mm):
2.02mm
End point (<3mm):
2.09mm
Baseline (3-6mm):
3.94mm
End point (3-6mm):
3.45mm
Baseline (>6mm):
6.72mm
End point (>6mm):
5.83mm
of the statistical tests
and neither standard
deviation nor
confidence intervals
are provided for the
mean scores.
Control group(s)
Baseline (whole mouth):
2.62mm
End point (whole mouth):
2.63mm
Baseline (<3mm):
2.11mm
End point (<3mm):
2.24mm
Baseline (3-6mm):
3.90mm
End point (3-6mm):
3.63mm
Baseline (>6mm):
7.15mm
End point (>6mm):
6.29mm
Standard deviations and
confidence intervals not
Evidence gaps:
Future research
should include
analysis of volunteernon-volunteer issues
to better determine
the generalisability of
research results.
Although we had a
significant effect on
plaque, we believe
our dichotomous
plaque measure was
insensitive to relative
improvements in
plaque levels.
Because plaque is a
better measure of
oral hygiene skill we
would suggest
instead using a
debris index that
measures both
calculus and plaque
as a measure of oral
hygiene skill rather
than clinical health.
Source of funding:
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
buccal margin,
brushing the lingual
gingival margin and
using a short-brush
stroke technique
Outcome measure:
Patients scored 2 for
demonstrating the
criteria on all teeth
observed in the arch,
1 for demonstrating
the criteria on at least
one-half of the teeth
observed in the arch,
and 0 for anything
else. The total index
score possible was 12
points each for
brushing and flossing
Outcome measure
validated: NR
Unit of
measurement: Index
score.
Time points
measured: Baseline
and 4 month follow-up
Outcome name: Selfreported flossing
Outcome definition:
Participants
completed a
questionnaire during
the baseline and
follow-up visits to
Results
Notes by review
team
reported
The National Institute
of Dental Research,
contract no. NOI-DE12589.
Net change scores
(change in intervention
group minus change in
control group – positive
score indicates greater
improvement in
intervention group or less
of a decline):
Whole mouth –0.08mm
p=0.174
< 3mm – 0.05mm
p=0.324
3-6mm – -0.21mm
p=0.004
>6mm – 0.03mm p=0.927
Outcome: Attachment
loss (mm) – mean scores
Intervention group(s):
Baseline (whole mouth):
9.73mm
End point (whole mouth):
9.79mm
Baseline (<3mm):
9.56mm
End point (<3mm):
9.58mm
Baseline (3-6mm):
9.10mm
End point (3-6mm):
10.02mm
Baseline (>6mm):
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
assess self-reported
brushing and flossing
frequency.
Outcome measure:
Times per week
Outcome measure
validated: NR
Unit of
measurement: Times
per week
Time points
measured: Baseline
and 4 month follow-up
Outcome name: Selfreported brushing
Outcome definition:
Participants
completed a
questionnaire during
the baseline and
follow-up visits to
assess self-reported
brushing and flossing
frequency.
Outcome measure:
Times per week
Outcome measure
validated: NR
Unit of
measurement: Times
per week
Time points
measured: Baseline
and 4 month follow-up
Results
Notes by review
team
13.07mm
End point (>6mm):
12.59mm
Control group(s)
Baseline (whole mouth):
9.67mm
End point (whole mouth):
9.75mm
Baseline (<3mm):
9.61mm
End point (<3mm):
9.60mm
Baseline (3-6mm):
9.84mm
End point (3-6mm):
9.88mm
Baseline (>6mm):
11.26mm
End point (>6mm):
10.87mm
Net change scores
(change in intervention
group minus change in
control group – positive
score indicates greater
improvement in
intervention group or less
of a decline):
Whole mouth –0.02mm
p=0.748
< 3mm – -0.03mm
p=0.672
3-6mm – 0.02mm
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Outcome name:
Patient satisfaction
(with intervention
programme)
Outcome definition:
Participant rating of
intervention
programme –
components included:
overall programme;
group leaders; weekly
bleeding checks; oral
hygiene instruction;
ideas for maintaining
good habits;
refundable
attendance deposit;
number of sessions;
session meeting time;
duration of each
session; meeting
room.
Outcome measure: 1
= not helpful at all
while 5 = very helpful
Outcome measure
validated: NR
Unit of
measurement:
Rating score Time
points measured:
Just one point – at the
last class
Results
Method of analysis
(indicate if ITT or
Intervention group(s):
Notes by review
team
p=0.697
>6mm – -0.01mm
p=0.825
Standard deviations and
confidence intervals not
reported
Behavioural results:
Outcome: Flossing skills
(12 point scale) – mean
scores
Intervention group(s):
Baseline: 8.2
End point: 11.1
Control group(s):
Baseline: 8.6
End point: 9.2
ANCOVA based P values
for comparing groups at
baseline and 4 month
follow up:
 Baseline: p=0.44
 Follow-up:
p=0.001
Outcome: Brushing skills
– mean scores
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders): No
indication that ITT
was used. No
adjustments for
baseline differences
were made but the
differences were not
found to be
statistically significant.
Chi-squared was
used for the
dichotomous
outcomes (plaque,
gingival bleeding,
bleeding on probing).
For the continuous
outcomes (pocket
depth, attachment
loss) data was
aggregated across
sites to produce
patient-level means at
baseline and followup. ANOVA
procedures were then
used to compare the
intervention and
control groups on
patient-level change
Results
Notes by review
team
Baseline: 7.5
End point: 10.5
Control group(s):
Baseline: 6.2
End point: 7.7
ANCOVA based P values
for comparing groups at
baseline and 4 month
follow up:


Baseline: p=0.07
Follow-up:
p=0.001
Outcome: Self-reported
flossing – mean scores
Intervention group(s):
Baseline: 4.9
End point: 6.8
Control group(s):
Baseline: 3.7
End point: 4.2
ANCOVA based P values
for comparing groups at
baseline and 4 month
follow up:


Baseline: p=0.16
Follow-up:
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
scores (i.e. baseline
minus follow-up
value). The oral
hygiene skills of the
groups after 4 months
were compared using
analysis of covariance
(ANCOVA) adjusting
for baseline skill level.
Results
Notes by review
team
p=0.001
Outcome: Brushing skills
– mean scores
Intervention group(s):
Baseline: 12.6
End point: 13.1
Control group(s):
Baseline: 10.4
End point: 10.4
ANCOVA based P values
for comparing groups at
baseline and 4 month
follow up:
 Baseline: p=0.09
 Follow-up:
p=0.001
Outcome: Patient
satisfaction (with
intervention programme)
Mean score during last
class for overall
programme: 4.9
Other results for this
outcome available in
Table 3 of article if
needed
Attrition details:
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
4 from intervention and 5
from control group either
refused further
participation or repeatedly
failed to attend numerous
scheduled visits
Conclusion: This
randomised trial of a
group intervention
programme for older
periodontal patients
showed that the
programme was practical,
well-received by the
target audience and
effective in improving oral
hygiene habits, skills and
clinical oral health
outcomes. Compared to
controls receiving usual
periodontal maintenance
care, intervention
increased flossing and
brushing frequency.
Brushing and flossing
skills were also
significantly better at
follow-up for the
intervention group.
Compared to controls,
intervention reduced
gingival bleeding by half
and bleeding on probing
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
by 22%. Plaque scores
also improved
significantly. Pocket depth
scores (for pockets 36mm at baseline only)
showed significant
improvements, probably
through reduction in
inflammation. As
expected no change in
attachment level was
noted for the control
group over this short
period and there was
therefore no reason to
expect treatment effects
for this outcome.
These findings indicate
that group intervention
can help patients maintain
improved oral hygiene
habits over a 4-month
period.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: C.
Loignon, P. Allison,
A. Landry2,
L. Richard, J.-M.
Brodeur,
and C. Bedos
Study design: Conducted
qualitative research based on
in-depth interviews with eight
dentists practising in
disadvantaged communities of
Montreal, Canada (abstract).
Because qualitative research is
particularly useful for exploring
complex phenomena about
which little is known (Bedos et
al., 2008), the authors
considered it most appropriate
for gaining in-depth
understanding of dentists’
experiences with people living
in poverty. (p.991 para.4)
Population the sample was
recruited from:
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Before interpreting our
results, we should point out
some potential
methodological limitations.
First, our study reflects the
experiences of a relatively
small number of dentists;
nevertheless, we consider
the sample size to be
appropriate, considering our
methodology. Indeed, we
attained data saturation and
achieved a depth and
complexity of data that could
hardly have been obtained
through quantitative
research (Guest et al.,
2006). Second, we advise
caution about the
generalisability of our
results. Our sample was
composed of dentists who
practise in a particular social
context and under a
healthcare system—that of
Quebec—whose
organisation differs in
several fundamental aspects
from those of the US or
European countries. (p.994
para.6)
Year: 2010
Citation: Loignon,
C., et al., Providing
humanistic care:
dentists'
experiences in
deprived areas.
Journal of Dental
Research, 2010.
89(9): p. 991-995.
Country of study:
Canada
Quality Score (++,
+, or -): +
Research aims, objectives,
and questions: Our objective
was to identify specific
approaches and skills
developed by dentists for more
effective treatment of people
living in poverty and
addressing their
needs.(abstract)
Theoretical approach
[grounded theory, IPA etc]:
The scientific literature
provides data on difficulties
encountered by health
professionals who treat people
living in poverty, but there is a
serious lack of evidence on
overcoming those difficulties
How sample was recruited:
Adopted a maximum
variation strategy (Patton,
2002) to recruit dentists with
various and contrasting
levels of professional
exposure to poverty. We
selected professionals
practising in different types
of disadvantaged
neighbourhoods; we sent
them a written invitation then
telephoned them to plan an
interview. (p.992 para.1).
We used a snowball
technique
(Patton, 2002)—with
participants being identified
by peers. We thereby
obtained a subsample of
eight dentists that was
homogeneous in terms of
skills and clinical approach to
people living in poverty, but
not necessarily in terms of
socio-demographic
characteristics. While this
group was part of a sample
of 33 dentists in the larger
study, we present only the
subsample results here. We
stopped recruiting after the
2 experienced researchers conducted
the semi-structured individual
interviews, which lasted from 90 to
120 min and were audio-recorded for
subsequent transcription. (p.992
para.4)
The researchers used an interview
guide that covered experience with
low-income patients, perceptions of
poverty, strategies used to resolve
problems associated with low-income
patients, and possible solutions to
improve access to care. Participants
were invited to express themselves
freely and provide illustrative
examples. (p.992 para.5)
To improve the rigor and credibility of
our results, three researchers were
heavily involved in the analysis, which
included interview debriefing,
transcript coding, and data display
and interpretation. In debriefings
immediately following each interview,
researchers reflected on the data
collection, summarised findings,
identified emerging hypotheses, and
prepared subsequent interviews. Two
researchers coded the transcripts
independently and compared their
Limitations identified by
review team:
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
(Stewart et al., 2005; Mercer et
al., 2007; Monnickendam et
al., 2007). Our study may be
the first to describe how some
dentists develop a sociohumanistic approach that
includes understanding
patients’ social context, taking
time and showing empathy,
avoiding moralistic attitudes,
overcoming social distances,
and favoring direct
contact.(p.994 para.4)
State how data were
collected:
What method(s): Semistructured interviews
By whom: Researchers
What setting: Montreal,
Canada (p.992 para.1)
When: 2004 to 2008 (p.992
para.1)
Population and Sample
Selection
eighth interview because we
reached saturation after the
sixth; the seventh and eighth
brought no new information.
(p.992 paras 2-3)
How many participants
recruited:
Sample characteristics
(o.992 Table1):
Age: 31-40=1; 41-50=3; 5160=1; 61-70=3
Sex: Female=2; Male=6
Sexual orientation:
Disability:
Ethnicity: Canadian=4;
Canadian (non-Western
background)=4
Religion: NR
Place of residence:
Neighbourhood of practice:
Multi-ethnic=3; Caucasian
French speaking=5 Poverty
rates between 38% and 53%
significantly above city’s
overall rate of 29% (p.992
para.7)
Occupation: Dentists
Education: NR
Socioeconomic position:
NR
Social capital: NR
Inclusion criteria: 2
inclusion criteria, which were
that participants had to: (1)
Outcomes and Methods of Analysis
work. As recommended by Miles
(Miles and Huberman, 1994), data
were then displayed in analytic
matrices covering 3 main themes of
interest: dentists’ experiences with
low-income patients, perception of
poverty, and strategies to overcome
difficulties with this clientele. To
ensure that interpretations were
grounded in data and not influenced
by researchers’ pre-existing views, the
interpretive process used
triangulation, as the 3 researchers
checked and validated their
interpretations. (p.992 para.6)
Key themes and findings relevant
to this review [with illustrative
quotes if available]
NOTE: Several interesting themes –
but I have only reported on those
which are relevant to oral health
messages:
Taking Time and Showing Empathy
All participants demonstrated empathy
regarding their patients’ living
conditions by taking time to talk with
them, showing their concern, and not
judging their low oral-health literacy.
One spoke of his empathy for a young
patient exposed to violence in the
family who was consequently
removed from her family by a
government agency. (p.993 para.4)
Notes by Review Team
The research question is
rather broad - a lot of things
besides oral health
messages would fit into
"more effective treatment".
The findings are only
partially relevant to our study
– and only a couple of the
key themes have been
reported here as a result.
There is some information
on researcher role (covered
analysis as well as
interviews). Also researcher
did invite participants to
express themselves freely but it’s not clear how
research was explained to
participants.
Only one data collection
method was used which
limits reliability of the
methodology.
Themes are discussed
generally - but not linked to
dentists in particular areas or
groups - however there are
only 8 respondents
More links could have been
made with the data in the
conclusion. The researchers
did consider that the findings
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
serve a clientele largely
composed of people living in
poverty, and (2) demonstrate
an openness to treating
them. (p.992 para.2)
Exclusion criteria: NR
Outcomes and Methods of Analysis
Notes by Review Team
Avoiding Moralistic Attitudes and
Accepting Compromises
Recognizing that people living in
poverty find it challenging to follow
treatment plans and practise good
oral hygiene, participants adopted the
strategy of remaining steadfast and
avoiding moralistic attitudes. They
considered that blaming patients was
ineffective because it impeded the
therapeutic alliance. (p.993 para.6)
might reflect the dentists'
pragmatism rather than just
their humanistic values.
While recognizing that even more
advantaged patients did not
necessarily practice good oral
hygiene, participants considered this a
major issue in disadvantaged areas.
Their approach was pragmatic and
realistic: They tried to motivate their
patients and negotiate the best
treatment option, but accepted
compromises to find common ground
(Table 3). (p.993 para.7)
Conclusions: In conclusion, our
research shows that, for better
treatment of people living in poverty,
some dentists develop, over years of
practice, an original approach mainly
based on empathy and
communication. Even though dentists
using this socio-humanistic approach
found it successful, further research
should be conducted to assess its
impact on access to dental services
and patients’ experience of care.
(p.995 para.5)
Evidence gaps and/or
recommendations for
future research:
Even though dentists using
this socio-humanistic
approach found it
successful, further research
should be conducted to
assess its impact on access
to dental services and
patients’ experience of care.
(p.995 para.5)
Source of funding: This
study was funded by the
Canadian Institutes of Health
Research and the Fonds de
la recherche en santé du
Québec. The first author was
supported by a post-doctoral
fellowship from the GREAS
1 (Public Health Agency of
Montreal) and by the
Strategic Training Program
in Applied Oral Health
Research
(CIHR–McGill University).
(p.995 para.6)
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Author: Meurman,
P. et al
Source
Population(s):
Finland. The health
authorities in Turku
Health Centre
pointed out 2
suburban areas for
this study. They
estimated the socioeconomic profiles
and sizes to be
comparable and
suitable for a
prevention
programme. The
entire cohort of 1275
children, born
between 1 January
1998 and 30 June
1999, and living in
either of the study
areas, was enrolled
in the study and
screened for mutans
streptococci (MS)
and were enrolled
into the study if they
were MS positive.
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported):
The areas were not randomly
assigned to study groups. For
practical reasons, the more
populated area, with two
employed hygienists was selected
for the intervention. Only one
hygienist was stationed in the
other area which then formed the
control group.
Outcomes:
Year: 2009
Citation:
Meurman, P., et
al., Oral health
programme for
preschool children:
a prospective,
controlled study.
International
Journal of
Paediatric
Dentistry, 2009.
19(4): p. 263-73.
Country of study:
Finland
Aim of Study: The
aim of this study
was to evaluate the
preventive effect of
a risk-based Oral
Health Promotion
(OHP) versus
traditional
programme on the
occurrence of
dental caries at
Setting: The study
was carried out in 2
of 4 public health
Report how confounding
factors were minimised: At
baseline, there were differences
between the groups, in relation to
the occupation of caretakers,
child´s gender, and MS
colonisation. Therefore, these
confounding factors had to be
controlled in the statistical
analyses. This increased the
validity of the study and improved
the possibilities to interpret the
outcomes.
Programme/Intervention
description:
Outcome name:
Dental caries
Outcome definition:
Proportion of children
with dental caries and
prevalence of dental
caries >0 at 5 years
Outcome measure:
screening
Outcome measure
validated: NR
Unit of
measurement: Dmft
%
Time points
measured: Exam at 3
years and 5 years
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any
baseline differences
in important
confounders): The
baseline demographic
differences and
differences in the
Results
Oral health (clinical)
results:
Notes by review team
Limitations identified
by author:
NR
The proportion of
children with dental
caries: dmft >0 at 5
years
%
MS+ white collar
Intervention: 13.8%
Control: 43.2%
MS+ blue collar
Intervention: 41.7%
Control: 37.3%
(The absolute risk
reduction (ARR) and
the number needed to
treat (NNT) values as
a measure of the
preventive effect of
the oral health
programme targeted
to MS-colonised
children in the
intervention group.
White collar families:
ARR 0.29, 95% CI
0.1–0.5, NNT 3, 95%
Limitations identified
by review team:
Study took place in
Finland – not reflective
of a UK dental practice
setting.
Study was not
randomised due to
practical reasons and
dentists were not blinded
to study groups.
Evidence gaps: NR
Source of funding: The
research fund of the
Finnish Dental
Organisations and
Sumen
Naishammaslaakarit r.y.Finnish Women Dentists’
Association.
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Study details
Population and
setting
Method of allocation to
intervention/control
preschool age. The
OHP for the MScolonised children
was based on
repeated
motivation and oral
health education,
and included the
use of xylitol
lozenges.
care areas of Turku,
Finland.
What was delivered:
All families (in both groups)
received OHP:
Oral health aspects were
emphasised by the public
paediatric health nurse and
by the dental personnel at the
ages of 6-8 months. And later
at 18 months. At these OHP
visits, the main topics were
dental health, oral bacteria
and transmission pathways,
planned regular meals,
avoiding sugar, choosing
healthy non-cariogenic food
drink and snacks, oral
hygiene, adequate use of
fluorides, the development of
teeth, and sucking habits.
Caretakers received a
toothbrush for the child
During the 18 month visit a
biofilm sample was taken.
The test result and
confirmation of earlier
explained health aspects
were given upon a call.
At the age of 3 a dentist
invited the child to a dental
clinic for examination
Thereafter the invitations
were sent individually approx.
every 18 months or more
frequently if the risk for caries
was considered high.
Study Design:
Non-RCT (CCT).
An age cohort of
794 Finnish
children, 446 in the
intervention group
and 348 in the
control group, was
followed from 18
months to 5 years
of age. The
children were
screened for
mutans
streptococci (MS)
in the dental
biofilm.
Quality Score (++,
+, or -): -
Location (urban or
rural): suburban
Sample
characteristics:
th
Age: 18 months to
5 years
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Occupation: The
occupation of the
primary caretaker in
the family was
categorised
according to the
Finnish official
statistical
classification, and
further dichotomised
in white collar and
blue collar
occupations
Education: Turku,
Finland
Socioeconomic
position: White
Outcome definitions
and method of
analysis
distribution of
colonized subjects in
the study groups were
analysed using the chi
squared test,
statistical significance
level being P < 0.05
Results
Notes by review team
CI 2–11; blue-collar
families: ARR –0.04,
95% CI –0.23–0.14.)
Prevalence of dental
caries (dmft>0 at 5
years) and means of
the dmft by
occupation: total and
by MS colonisation (+
or -) and gender
% and mean (SEM):
White collar total:
Intervention: 11.4%
and 0.31 (0.09)
Control: 14.7% and
0.54 (0.12)
White collar girls+
Intervention: 18.2%
and 1.27 (0.85)
Control: 44.4% and
2.17 (0.77)
White collar girlsIntervention: 8.8%
and 0.16 (0.08)
Control: 9.1% and
0.17 (0.07)
White collar boys+
Intervention: 11.1%
and 0.22 (0.17)
Control:42.1% and
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Study details
Population and
setting
Method of allocation to
intervention/control
External
Validity(++, +, or ): +
collar / blue collar
occupations
Social capital: NR
Additional intervention for families
in intervention group (intervention
OHP was delivered to MS positive
subjects in the intervention group
p.266, Table 2):
Health nurses mentioned
habitual use of xylitol
products could be continued
also during pregnancy and
after birth.
After positive result of
screening test, the first
invitation to hygienist’s office
was sent to the child with its
caretakers.
Results of screening test
discussed during visit
Healthy oral habits and
dietary aspects were stressed
Caretakers were motivated to
ensure adequate use of
fluorides and good oral
hygiene of the child
Toothbrushing demonstrated
if necessary
Free xylitol/maltitol lozenges
offered (available until third
birthday) – recommended 2
lozenges 3 times daily
Instructions given orally and
in writing
For MS-positive subjects, the
second invitation to the
hygienist’s office was due
after 3 months and thereafter
Eligible population
(describe how
individuals,
groups, or clusters
were recruited, e.g.
media
advertisement,
class list, area): 2
suburban study
areas - The entire
cohort of 1275
children, born
between 1 January
1998 and 30 June
1999, and living in
the 2 study areas
identified by the
Turku Health Centre,
were screened for
MS.
State if eligible
population is
considered by the
study authors as
representative of
the source
population:
Entire cohort were
selected and
screened.
Outcome definitions
and method of
analysis
Results
Notes by review team
1.79 (0.67)
White collar boysIntervention: 12.9%
and 0.33 (0.13)
Control: 6.1% and
0.24 (0.13)
Blue collar total:
Intervention: 25.4%
and 1.00 (0.13)
Control: 27.4% and
0.54 (0.12)
Blue collar girls+
Intervention: 31.8%
and 2.14 (0.10)
Control: 34.5% and
1.14 (0.37)
Blue collar girlsIntervention: 15.7%
and 0.40 (0.80)
Control: 19.2% and
0.73 (0.27)
Blue collar boys+
Intervention: 47.4%
and 2.24 (0.50)
Control: 40.9% and
1.09 (0.34)
Blue collar boysIntervention: 26.2%
and 0.93 (0.20)
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Study details
Population and
setting
Method of allocation to
intervention/control
Inclusion Criteria:
The inclusion criteria
were: Finnish
background,
information of
gender, performed
screening test at 18
months, and a
clinical examination
at the age of 5 years
± 6 months. A total
of 794 children met
with the inclusion
criteria, 446 in the
intervention group
and 348 in the
control group.
every 6 months until the age
of 5 years
At the following visits, the
caretakers received repeated
information on healthy habits,
brushing fluorides, meals,
snacks and drinks
The hygienist were encouraged to
create a supportive relaxed
atmosphere
Theoretical basis: NR
By whom: 54 dentists carried out
all exams; 2 specially trained
dental hygienists carried out
screening, clinic visits and the
OHP.
To whom: Caretakers of children
received OHP (and childrenexams)
How delivered: OHP given orally
and in writing during the visits
When/where: Study took place
from June 1999 to December
2004. Health Centres Turku
How often: 18 months screening,
second invitation to the hygienists
office due after 3 months and
thereafter every 6 months until
the age of 5 years.
How long for: Age 18 months to
5 years of age (3.5 years)
Exclusion Criteria:
89 subjects
excluded due to
ethnicity (before
enrolment) – unclear
on reasons
% of selected
individuals agreed
to participate:
1186 enrolled, 58
were not screened =
1128. 95%. (not all
completed the study
– 794 completed)
Potential sources
of bias:
Control/Comparator
description:
What was delivered: All families
Outcome definitions
and method of
analysis
Results
Notes by review team
Control: 25.9% and
0.74 (0.21)
A significantly lower
caries prevalence was
found only in the
White collar
background children in
the intervention group
(ARR 0.29, 95% CI
0.1–0.5, NNT 3, 95%
CI 2–11): in girls, the
prevalence of caries
(dmft > 0) was 18% in
the intervention group,
and 44% in the control
group. The
corresponding figures
were 11% and 42% in
boys (Table 4 p.268).
In blue collar
background children,
no differences
between the groups
were found. The same
phenomena were
seen in the mean dmft
values (Table 4).
Prevalence of carious
lesions (idmft >0 at 5
years)
%:
White collar total
Intervention group:
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Study details
Population and
setting
Method of allocation to
intervention/control
(in both groups) received OHP:
Oral health aspects were
emphasised by the public
paediatric health nurse and
by the dental personnel at the
ages of 6-8 months. And later
at 18 months. At these OHP
visits, the main topics were
dental health, oral bacteria
and transmission pathways,
planned regular meals,
avoiding sugar, choosing
healthy non-cariogenic food
drink and snacks, oral
hygiene, adequate use of
fluorides, the development of
teeth, and sucking habits.
Caretakers received a
toothbrush for the child
During the 18 month visit a
biofilm sample was taken.
The test result and
confirmation of earlier
explained health aspects
were given upon a call.
At the age of 3 a dentist
invited the child to a dental
clinic for examination
Thereafter the invitations
were sent individually approx.
every 18 months or more
frequently if the risk for caries
was considered high.
By whom: 54 dentists carried out
all exams
Outcome definitions
and method of
analysis
Results
Notes by review team
29.3%
Control group:
29.8%
White collar girls+
Intervention: 36.4 %
Control: 61.1%
White collar girlsIntervention: 20.6%
Control: 23.9%
White collar boys+
Intervention: 44.4%
Control: 57.9 %
White collar boysIntervention: 32.9%
Control: 21.2%
Blue collar total
Intervention group:
40.9%
Control group:
43.3%
Blue collar girls+
Intervention: 59.1%
Control: 44.8%
Blue collar girlsIntervention: 26.9%
Control: 36.5%
Blue collar boys+
Intervention: 63.2%
278
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
To whom: Caretakers of children
received OHP (and childrenexams)
How delivered: OHP given orally
and in writing
When/where: Study took place
from June 1999 to December
2004. Health Centres Turku
How often: 18 months screening
for MS +/-, clinical exam
thereafter at 3 years and 5 years.
How long for: 3.5 years
Sample size at baseline:
Total sample N = 1128
Intervention group N = 617
Control Group N = 511
Baseline comparisons (report
any baseline differences
between groups in important
confounders): Between the
study groups a significant
difference was found in the
proportion of blue collar families
and the proportion of MScolonised children. Confounding
factors were controlled in the
statistical analysis
Study sufficiently powered
(power calculations and
provide details):
On the grounds of the results of a
short pilot study, around 25–30%
Outcome definitions
and method of
analysis
Results
Notes by review team
Control: 59.1%
Blue collar boysIntervention: 43.2%
Control: 42.6%
In the intervention
group, 52% of the MS
positive white collar
children, and 50% of
the blue collar children
regularly used the
specially
manufactured xylitol
lozenges, whereas the
other half either used
the lozenges
irregularly or had
stopped using. 3
mothers reported
laxative effects as
adverse effects and as
the reason for
discontinued use of
lozenges, and one
mother reported
preferring to give only
half a dose of
lozenges. In the
intervention group,
among the MSpositive children, no
significant differences
between regular users
versus irregular users
of the xylitol lozenges
279
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
of children were estimated to be
MS colonised in early childhood.
Of the MS-colonised Finnish
children, 37% were estimated to
develop dental caries up to the
age of 5 years. To obtain an
absolute risk reduction (ARR) of
10%, which was considered
clinically significant, around 1000
children should be enrolled in the
study.
Outcome definitions
and method of
analysis
Results
Notes by review team
were found in relation
to caries (p.269).
Attrition details
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control):
Altogether, 1128 of
the 1186 Finnish
children were
screened for MS. Of
the 58 unscreened,
20 children were sick
or treated by
antibiotics at the time,
36 either had moved
from the area, or for
other reasons did not
visit the hygienist.
During the follow-up
period, if the family
moved to another area
within the city, the
children were
examined by the
dentist in the
respective area and
they remained as
study participants.
Altogether, 334
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
children dropped out
because the family
had either moved out
of the city (256 cases)
or they were excluded
if the 5-year dental
examination did not
come about within the
time limit. Reasons
mentioned for
absence/delay (51
cases) were
temporary visit
abroad, logistic
problems, illnesses,
family causes such as
a newborn baby at
home, unsuitable
working hours,
ongoing dental
treatment, and
sickness leave of the
dentist. The reason for
absence remained
unnoticed in 27 patient
records. Of the dropouts, the demographic
factors, gender,
carious lesions at
baseline, and
proportion of risk
subjects were
analysed based on
available information.
No significant
differences between
281
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
the drop-outs and the
analysed were found
in either study group.
Conclusion:
In the present
population, with
relatively low caries
prevalence, the MS
colonisation in the
dental plaque (biofilm)
and the occupation of
caretaker are strongly
related to dental
caries at the age of 5
years. The present
programme seems to
have a better
preventive effect on
dental caries in white
collar families than in
blue-collar families.
For blue collar
families, different
kinds of methods for
oral health promotion
and support are
additionally needed.
282
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: I. Mills, J.
Frost, E. J. Kay
and D. R. Moles
Study design: The study
consisted of in-depth
qualitative interviews (p.5,
para. 3).
Population the sample
was recruited from:
Southwest England.(p.5,
para.4)
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Research aims, objectives,
and questions: This study
aims to provide an
understanding on the term
Person-Centred Care (PCC)
from a patients’ perspective
and introduce a model, which
may be considered relevant in
subsequent refinements of the
Dental Quality ad Outcomes
Framework (DQOF) (p.5,
para. 2).
How sample was
recruited: Recruitment was
achieved through
advertising and promotion of
the study with GP practices,
Peninsula Dental school
facilities and by word of
mouth. (p.5, para. 4 and p.6,
para.1). Recruitment of
participants continued until
no new themes were
identified by the research
team (p.7, para.1).
The data were analysed using a
thematic approach (p.7, para.1). This
was inductive and followed the process
of familiarisation, coding, display,
organisation and identification of
themes. NVivo software was used to
organise the data and support
generation of codes, prior to
aggregation and development of broad
themes. (p.7, para.1).
Year:
Citation: Mills, I.,
Frost, J., Kay, E.
J., and Moles, D.
R. (in press)
Measuring patient
experience – A
model of personcentred care in
dentistry.
Country of study:
UK
Quality Score (++,
+, or -)
++
Theoretical approach
[grounded theory, IPA etc]:
Thematic analysis (p.7, para.
1).
How many participants
recruited: 15 participants.
(p. 6, para. 2).
State how data were
collected:
What method(s): 15 in-depth
semi-structured interviews
were collected. A topic guide
was used during the interview,
which were tested during 4
pilot interviews. The 15
interviews took place at
locations which were
convenient for the participants
and lasted between thirty and
eighty minutes. The interviews
Sample characteristics:
Age: The age range was
between 21 and 76 years of
age (p.6, para.2).
Sex: NR
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Southwest England (p.5,
para.4).
Occupation: NR
Key themes and findings relevant to
this review [with illustrative quotes if
available]
A number of themes were identified
through the interviews and were
categorised as functional or relational
aspects of care (p.7, para.3).
Functional aspects referred to the
healthcare system and the physical
environment, which appeared to have
an indirect influence on PCC. The
following findings were therefore based
on the relational aspects that were
identified (p.7, para.3).
In terms of relational aspects of care,
five components of PCC were identified
these were: connection, attitude,
Our study reports the
experiences and views of a
relatively small number of
patients who were all based
in the Southwest of England
(p.13, para.2).
Limitations identified by
review team:
The paper does not clearly
describe how the research
was explained to the
participants.
A breakdown was not
provided for the number of
participants who were male
or female.
Only one method was used
for data collection.
Not many examples from
the interviews were
provided within the paper.
No comparison was made
(or stated that there was no
difference) between gender
or age group.
Only one limitation was
283
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
were audio-digitally recorded
and professionally transcribed
verbatim.(p.6, para.2 and 3).
Population and Sample
Selection
Education: NR
Socioeconomic position:
NR
Social capital: NR
By whom: The lead author
(p.6, para.2).
Outcomes and Methods of Analysis
Notes by Review Team
communication, empowerment and
feeling valued. (p.7, para.4).
Theoretically they may appear as
distinct entities but in practical terms
they are closely related and
interdependent (p.8, para.1).
discussed.
Evidence gaps and/or
recommendations for
future research: NR
Inclusion criteria: NR
What setting: Locations
which were suitable for the
participants. (p.6, para.3).
When: The interviews were
collected during February and
August 2014. (p.6, para.2).
Exclusion criteria: NR
Connection
Connection was felt to underpin the
professional relationship and the
continuity of care played an important
role in facilitating this. Patients
expressed a strong preference for
having access to a regular dentist as
they greatly value familiarity,
consistency and continuity of care. They
consider their dental provider as “my
dentist” and have established a strong
working relationship. For some this is
based on a long term relationship and
familiarity but for others it is based on a
‘good fit’ with engagement, rapport and
shared values/beliefs viewed as
important criteria. Some described the
difficulties and frustrations with a
constantly changing dentist “if I look at
recent experiences one of the problems
is that even though we’re probably there
every nine to 6 months at the moment I
would say that you see a different
(dentist), the turnover is very very high,
we’re probably turning over dentists
every 12, 18 months”. (p.8, para.2)
Source of funding: NR
Attitude
A caring, understanding and empathetic
approach is greatly valued, with patients
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
appreciative of a relaxed, calm manner
and a gentle considerate approach. An
uncaring or ambivalent approach was
highly criticised, particularly where
physical discomfort was experienced
during treatment. Dental anxiety was
attributed to previous experience of pain
which had not been acknowledged or
dealt with. Patients expected to be
treated professionally with respect and
dignity in a non-judgemental manner.
Small gestures of support were greatly
appreciated and appeared to
demonstrate that staff genuinely care “I
didn’t feel warmth from the person, I feel
like I was a bit irritating, so what I
wanted was somebody who
understands you’re a nervous patient,
will have some patience with you…will
kind of go, ok, I need someone who’s
quite super-calm, kind of a warmth in
their voice” (p.8, pa3 and p.9, para.1).
Communication
Patients highlighted concerns around
communication when they are not
provided with adequate information.
This lack of communication was
identified as being due to a number of
reasons including lack of information,
poor communication skills, attitude,
failure to listen, use of technical
language, poor English language skills
or lack of time available. (p.9, para.1).
Patients wanted the opportunity and
time to be listened to, and also a
285
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
demonstration that their “voice” had
been heard. “Well it isn’t just listened to,
it’s demonstrated that, there needs to
be a demonstration that you’ve been
listened to doesn’t there”. (p.9, para.1).
Patients generally wanted a level of
information which would allow them to
make informed decisions about their
own care; it was seen as inadequate if
this was not achieved. (p.9, para.2).
Communication difficulty with non-UK
dentists was mentioned repeatedly and
was often associated with unfamiliarity
due to a lack of continuity care.(p.9,
para.2).
Effective communication between
professionals was considered important
to ensure coordinated care. (p.9,
para.3).
Empowerment
Patients expressed feelings of
vulnerability when visiting the dentist
and this often stemmed from a previous
bad experience when they felt a loss of
control. Acknowledgement, reassurance
and support from the dental team were
considered very important in addressing
this “Just smiling and being comforting
and not making me feel like I didn’t have
to do anything I didn’t want to do.
Letting me be in control of it slightly”.
(p.10, para.2).
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Patients appreciated the opportunity to
discuss options and have an influence
on decisions about their care.
Participants estimated that they were
happy to be less involved in shared
decision making with simple of
emergency procedures but wanted
more detailed information for more
complex or elective treatments. (p.10,
para.3).
Value
Feeling valued and appreciated was at
the centre of most patients’ views on
visiting the dentist. This was in terms of
time, respect and being treated as an
individual (p.10, para.4).
Conclusions: Effective evaluation of
patient experience is a fundamental
aspect of improving quality in NHS
dentistry. The current approaches to
evaluation within dentistry do not
appear to measure patient experience
adequately. (p.13, para.3).
This paper proposes a model of PCC
for dentistry to illustrate the themes
which were identified; these were the
relational aspects of care. The findings
reinforce the importance which patients
place on relational aspects of care and
how they predominantly use this to
assess the quality of care provided. The
model also includes functional aspects
of care; these were considered to also
have an impact on the delivery of PCC.
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
(p.12, para.2 and 3).
This study provides a unique insight into
patients understanding of personcentred care by using first order
constructs through personal
experiences. The model proposed has
been generated from empirical evidence
using sound qualitative methods with
the hope that this may inform and
influence development of a tool to
measure PCC within any future version
of the DQOF. (p.13, para.3).
288
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Munster
Halvari, A, E. et al
Source
Population(s):
Norway.
207 potential
participants from the
University of Oslo
indicated interest in
the study on
motivation and dental
behaviour after
seeing a poster or
being approached by
the researcher.
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): NR. No information
given on how participants were
randomised
Outcomes (include
details of all relevant
outcome measures
and whether measures
are objective or
subjective or otherwise
validated):
Oral health (clinical)
results:
Limitations
identified by author:
Plaque (T1a and T2)
Mean (SD), α:
Sample size too
small:
Due to small sample
size, the SDT model
was simplified: could
not include change in
gingivitis in the
structural model
tested, but we used
bootstrapping
separately to test the
indirect link between
changes in behaviour
and gingivitis through
change in dental
plaque
Year: 2012
Citation: Münster
Halvari, A.E., et al.,
Self-determined
motivational
predictors of
increases in dental
behaviours,
decreases in dental
plaque, and
improvement in oral
health: A
randomised clinical
trial. Health
Psychology, 2012.
31(6): p.777-788.
Country of study:
Norway
Aim of Study: The
present study tested
the hypotheses that:
(a) a dental
intervention
designed to
promote dental care
competence in an
autonomysupportive way,
Setting: In a dental
clinic – not clear
where, participants
were from the
University of Oslo.
Location (urban or
rural): Oslo
Sample
characteristics:
Age: 18-32 years
Sex: 71% female
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
students at the
Report how confounding
factors were minimised: There
were no significant differences
between completers from the two
groups with the exception of
gender which was controlled for
when the MANOVA was run.
Gender was found not to be
significant as a main effect or
interaction.
Programme/Intervention
description:
What was delivered:
Initial exam: plaque and gingivitis.
Psychological questionnaire:
covering autonomy orientation,
perceived competence,
autonomous motivation for home
care, dental behaviours,
demographics
45 minute intervention: Dental
hygienist began intervention by
asking participants about their
perceived oral health and
Outcome name:
Perceived autonomy
support (T1c)
Outcome definition:
Perceived autonomy
support was measured
with the 6-item version
of the Health Care
Climate Questionnaire
(Williams et al., 1996).
A sample item is, “I feel
that my dental
professional has
provided me choices
and options in relation
to my daily oral home
care.”
Outcome measure:
Questionnaire
Outcome measure
validated: Yes - The
scales for measuring
motivation variables
were found reliable in
previous research:
autonomy support
(α=.96, Williams et al.,
Total sample: NR
Baseline: NR
Follow up (all time
points): N/A
End point: NR
Intervention
group(s):
Baseline: 1.31 (0.29),
0.93
Follow up (all time
points): N/A
End point: 0.51
(0.19), 0.95
ANOVA Results:
F=24.31 Cohen’s d=0.86 95% Ci= -0.81 to
-0.91 p<0.001
Control group(s)
Baseline: 1.27 (0.26),
0.93
Follow up (all time
points): N/A
End point: 0.90
(0.27), 0.95
Gingivitis (T1a and
T2)
Changes in
motivation, behaviour,
plaque, and gingivitis
were assessed at the
same time, so we
cannot conclude that
the motivation
variables produced
the changes in dental
behaviour, plaque,
and gingivitis.
Limitations
identified by review
team:
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Study details
Population and
setting
Method of allocation to
intervention/control
relative to standard
care, would
positively predict
perceived clinician
autonomy support
and patient
autonomous
motivation for the
project, increases in
autonomous
motivation for dental
home care,
perceived dental
competence, and
dental behaviours,
and decreases in
both dental plaque
and gingivitis over
5.5 months; and (b)
the selfdetermination
theory process
model with the
intervention and
individual
differences in
autonomy
orientation positively
predicting project
autonomous
motivation and
increases in
perceived dental
competence, both of
which would be
associated with
University of Oslo
Occupation:
Students
Education:
University students
Socioeconomic
position: NR
Social capital: NR
problems and listening to and
acknowledging their feelings and
perspectives before giving
competence-related information
about their perceived oral health
and problems. Based on this
conversation the contents of the
intervention were:
 Education in plaquerelated diseases such as
gingivitis, periodontitis and
caries
 Demonstrating effective
brushing and flossing with
participants practising
these tasks
 Giving health promotion
and disease preventive
information and offering
rationales for dental
behaviours by explaining
the relations of behaviours
to disease prevention and
health
 Giving information about
the value of fluorides and
regular meals
 Offering choice and
options concerning dental
home care.
Followed by teeth cleaning done
in an autonomy-supportive way.
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g.
media
advertisement,
class list, area):
students from the
University of Oslo
indicated interest in
the study on
motivation and dental
behaviour after
seeing a poster or
being approached by
the researcher.
State if eligible
population is
considered by the
study authors as
representative of
the source
population: NR. No
demographic
information is
All participants responded to
questionnaires assessing
Outcome definitions
and method of
analysis
1996)
Unit of measurement:
Scale: 1 (strongly
disagree) to 7 (strongly
agree)
Time points
measured:
Immediately after
intervention and/or
cleaning
Outcome name:
Autonomous
motivation for the
Dental Project (T1c)
Outcome definition:
This aspect of the
study was assessed by
the Evaluation of
Dental Project Scale
(Halvari and Halvari,
2006). 4 items
focussed on
participants’ interest,
engagement, and
curiosity toward the
project. A sample item
is, “In this project I
have become more
interested in my dental
health.”
Outcome measure:
Questionnaire
Outcome measure
validated: Yes - The
Results
Notes by review
team
Mean (SD), α:
Total sample:
Baseline: NR
Follow up (all time
points): N/A
End point: NR
Intervention
group(s):
Baseline: 1.47 (0.15),
0.88
Follow up (all time
points): N/A
End point: 1.17
(0.10), 0.94
ANOVA results:
F=52.27 Cohen’s d=1.21 95% Ci= -1.18 to
-1.24 p<0.001
Control group(s)
Baseline: 1.44 (0.15),
0.88
Follow up (all time
points): N/A
End point: 1.17
(0.10), 0.94
Behavioural results:
Perceived autonomy
support (T1c)
Mean (SD), α:
Very little information
on the source
population. Other
than, the participants
were all students from
the University of Oslo.
No demographic
information is
provided on the
source population to
compare with those
who are eligible and
there is no information
on how participants
were initially recruited.
Inclusion and
exclusion criteria
unclear.
No information on
how randomisation
was undertaken.
Evidence gaps:
A result of the
ANCOVA indicated
that control group
participants showed a
decrease in plaque
but an increase in
gingivitis. It is possible
that the plaque
290
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Study details
Population and
setting
Method of allocation to
intervention/control
increases in dental
behaviour, which
would, in turn, lead
to decreased plaque
and gingivitis.
Study Design:
Parallel RCT
provided on the
source population to
compare with those
who are eligible and
there is no
information on how
participants were
initially recruited.
Quality Score (++,
+, or -): ++
Inclusion Criteria:
NR
External
Validity(++, +, or -):
+
Exclusion Criteria:
Not specifically
reported.
However, of the 207
students, 158 (a)
showed up at the
clinic, (b) did not
have periodontal
pockets _4.0 mm, as
measured by a
pocket probe, and/or
serious bone loss
visualised by digital X
rays during the
dental examination,
(c) did not have
significant additional
oral or other
diseases, (d) were
not pregnant, (e)
understood
Norwegian, and (f)
gave informed
consent.
perceived clinic autonomy support
and autonomous motivation for
the dental project.
Follow-up after 5.5 months:
questionnaire covering perceived
competence, autonomous
motivation for home care, dental
behaviours. Dental clinic exam:
plaque, gingivitis. (Followed by
teeth cleaning and debriefing).
Theoretical basis: Selfdetermination theory process
model (SDT)
By whom: Dental hygienist
To whom: Participants (university
students)
How delivered: Use of SDT:
Listening to and acknowledging
feelings, providing education,
offering choices, demonstrating
techniques.
Teeth cleaning was done in an
autonomy-supportive way.
When/where: Dental clinic
How often: Just one episode of
the intervention. Cleaning and
questionnaire twice - (pre and post
intervention)
How long for: Intervention study
took place over 5.5 months
Control/Comparator
description:
What was delivered:
Outcome definitions
and method of
analysis
scales for measuring
motivation variables
were found reliable in
previous research:
autonomous motivation
toward the dental
project (α= .85, Halvari
and Halvari, 2006)
Unit of measurement:
scale: 1 (not at all true)
to 7 (very true)
Time points
measured:
Immediately after
intervention and/or
cleaning
Outcome name:
Autonomous
motivation for dental
home care (T1a and
T2)
Outcome definition: A
3-item identified
subscale of the SelfRegulation for Dental
Home Care
Questionnaire (Halvari
et al., in press[a])
measured autonomous
motivation. A sample
item is, “I do my dental
home care because I
think it is the best for
me, and it is in my
Results
Notes by review
team
Total sample: NR
Baseline: NR
Follow up (all time
points): N/A
End point: NR
decrease may be
related to a
phenomenon
observed in the dental
clinic field, namely,
that patients exert
extra effort in cleaning
their teeth right before
their clinic visit, which
would remove plaque.
If, at follow-up, these
control group
participants, who
showed only a small
increase in dental
behaviours (Cohen’s
d _ .19; 95% CI [.02
to .35]) relative to a
large increase in the
experimental group
(Cohen’s d _ .64; CI
[.48 to .80]), exerted
extra effort they would
have removed plaque
without affecting the
gingivitis that resulted
from inadequate
dental behaviours for
the prior 5.5 months.
If this were true, it
would emphasise the
importance of having
a competenceenhancing
intervention, such as
the one in this trial,
Intervention
group(s): n=79
Baseline: NR
Follow up (all time
points): Immediately
after intervention
and/or cleaning: 6.61
(0.48), 0.96
NR
End point: NR
Univariate ANOVA
result – intervention
: F = 148.98, Cohen’s
d= 1.38, 95% CI:
1.14-1.62, p<0.001
Control group(s):
n=79
Baseline: NR
Follow up (all time
points): Immediately
after intervention
and/or cleaning: 4.14
(1.73), 0.96
End point: NR
Autonomous project
motivation (T1c)
Mean (SD), α:
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Study details
Population and
setting
Method of allocation to
intervention/control
Initial exam: plaque and gingivitis.
% of selected
individuals agreed
to participate:
49 refused to
participate (out of
207) = 23.7%
Potential sources of
bias:
NR
Psychological questionnaire:
covering autonomy orientation,
perceived competence,
autonomous motivation for home
care, dental behaviours, and
demographics.
Followed by teeth cleaning done
in an autonomy-supportive way.
All participants responded to
questionnaires assessing
perceived clinic autonomy support
and autonomous motivation for
the dental project.
Follow-up after 5.5 months:
questionnaire covering perceived
competence, autonomous
motivation for home care, dental
behaviours. Dental clinic exam:
plaque, gingivitis. (Followed by
teeth cleaning and debriefing).
(The control group were also
offered the intervention after the
trial had concluded)
By whom: Dental hygienist
To whom: Participants (university
students)
How delivered: Teeth cleaning
was done in an autonomysupportive way.
Outcome definitions
and method of
analysis
interest to do so.”
Outcome measure:
Questionnaire
Outcome measure
validated: Yes - The
scales for measuring
motivation variables
were found reliable in
previous research:
perceived competence
and autonomous
motivation for home
care (αs .88 and .81,
respectively, Halvari et
al., 2010, in press[a]).
Unit of measurement:
7-point Likert scale
from 1 (not at all true)
to 7 (very true)
Time points
measured: Prior to
randomisation and
after 5.5 months
Outcome name:
Perceived dental
competence (T1a and
T2)
Outcome definition:
This was assessed by
the Dental Coping
Beliefs Scale (Wolfe,
Stewart, Meader, and
Hartz, 1996) using the
five items with the best
factor loadings (see
Results
Total sample: NR
Baseline: NR
Follow up (all time
points): N/A
End point: NR
Intervention
group(s): n=79
Baseline: NR
Follow up (all time
points): Immediately
after intervention
and/or cleaning: 6.01
(0.84), 0.91
End point: NR
Univariate ANOVA
result – intervention
: F=52.68 Cohen’s d=
0.92 95% CI= 0.631.22 p<0.001
Control group(s):
n=79
Baseline: NR
Follow up (all time
points): Immediately
after intervention
and/or cleaning: 4.80
(1.22), 0.91
End point: NR
Notes by review
team
because it would
indicate that just
standard care, even if
autonomy supportive,
was not adequate to
yield the desired
outcome. Future
research could shed
further light on this
(p.786).
Source of funding:
The Faculty of
Odontology,
University of Oslo,
funded the 4-year
PhD period (not whole
study)
The Norwegian
Ministry of Health,
funded part of the
study, which made it
possible to engage a
second dental
hygienist to perform
the “blinded”
measures of dental
plaque and gingivitis.
Autonomous
motivation for dental
home care (T1a and
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Study details
Population and
setting
Method of allocation to
intervention/control
When/where: Dental clinic
How often: Cleaning and
questionnaire twice - (pre and post
intervention)
How long for: Study took place
over 5.5 months.
Sample size at baseline:
Total sample N = 158
Intervention group N = 79
Control Group N = 79
Baseline comparisons (report
any baseline differences
between groups in important
confounders):
Among completers, the
experimental and control groups
were not significantly different in
baseline measures (logistic
regression), demographics, or in
the time between T1 and T2
assessments (ANOVA). There
were, however, significant gender
differences in the make-up of the
2 groups (p<0.01) with more
females (57.42%) in the control
group than the experimental group
(42.48%). Thus gender was
controlled for in the subsequent
multivariate analysis of variance.
Gender was found not to be
significant as a main effect or
interaction.
Outcome definitions
and method of
analysis
Halvari and Halvari,
2006) and 2 added
items from a previous
study (Halvari et al.,
2010). A sample item
is, “I believe I can
remove most of the
plaque from my teeth
on a daily basis.”
Outcome measure:
Questionnaire
Outcome measure
validated: Yes - The
scales for measuring
motivation variables
were found reliable in
previous research:
perceived competence
and autonomous
motivation for home
care (αs .88 and .81,
respectively, Halvari et
al., 2010, in press[a]).
Unit of measurement:
Scale: 1 (not at all true)
to 7 (very true)
Time points
measured: Prior to
randomisation and
after 5.5 months
Outcome name:
Dental health
behaviour (T1a and
T2)
Outcome definition:
Results
Notes by review
team
T2)
Mean (SD), α:
Total sample:
Baseline: NR
Follow up (all time
points): N/A
End point: NR
Intervention
group(s):
Baseline: 5.85 (0.89),
0.76
Follow up (all time
points): N/A
End point: 5.83
(0.79), 0.72
Other results: F=0.23
Cohen’s d=-0.09 95%
Ci= -0.26 to 0.10
p>0.05
Control group(s):
Baseline: 5.96 (0.90),
0.76
Follow up (all time
points): N/A
End point: 5.85
(0.99), 0.72
Perceived dental
competence (T1a and
T2)
Mean (SD), α:
Total sample:
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Study details
Population and
setting
Method of allocation to
intervention/control
Study sufficiently powered
(power calculations and provide
details):
A power analysis using data form
a previous study (Halvari and
Halvari 2006) indicated that the
necessary number of participants
in each group should be 14 for
dental plaque, to detect significant
differences (using t tests) between
averages for the experimental and
control groups with a power of .90
(α=.05).
Outcome definitions
and method of
analysis
Dental health
behaviour was
assessed by a 4-item
formative composite
scale (Halvari et al.,
2010). The items are
(a) “I am very
determined to brush
my teeth as accurately
as possible,” using a 1
(not at all true) to 7
scale (very true), (b)
“How often do you
brush your teeth?”
using responses from 1
(quite seldom) to 5 (3
times a day or more);
(c) “How often do you
use dental floss for
cleaning the areas
between your teeth”
using responses from 1
(never) to 5 (daily); and
(d) “How many regular
meals do you have per
day?” using responses
from 1 (1 meal) to 5 (5
or more meals).
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
Scales (various): 1 (not
at all true) to 7 (very
true); 1 (quite seldom)
Results
Notes by review
team
Baseline: NR
Follow up (all time
points): N/A
End point: NR
Intervention
group(s):
Baseline: 4.30 (0.86),
0.80
Follow up (all time
points): N/A
End point: 5.17
(0.84), 0.86
Other results: F=4.30
Cohen’s d=0.37 95%
Ci= 0.20 to 0.59
p<0.05
Control group(s)
Baseline: 4.37 (0.98),
0.80
Follow up (all time
points): N/A
End point: 5.17
(0.84), 0.86
Dental health
behaviour (T1a and
T2)
Mean (SD):
Total sample:
Baseline: NR
Follow up (all time
points): N/A
End point: NR
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
to 5 (3 times a day or
more); 1 (never) to 5
(daily); and 1 (1 meal)
to 5 (5 or more meals)
Time points
measured: Prior to
randomisation and
after 5.5 months
Outcome name:
Plaque (T1a and T2)
Outcome definition:
The Dental Plaque
Index (Löe, 1967)
reflects soft deposits
on the tooth surface
and is anchored by a
scale ranging from a
score of 0 (absence of
plaque) to 3
(abundance of soft
matter within the
gingival pocket and/or
on the tooth and
gingival margin)
Outcome measure:
Index score
Outcome measure
validated: NR
Unit of measurement:
Ranges from 0
(absence of plaque) to
3 (abundance of soft
matter within the
gingival pocket and/or
on the tooth and
Results
Notes by review
team
Intervention
group(s):
Baseline: 3.70 (0.59)
Follow up (all time
points): N/A
End point: 4.11
(0.55)
Other results: F=0.90
Cohen’s d=0.16 95%
Ci= 0.04 to 0.30
p>0.05
Control group(s)
Baseline: 3.76 (0.71)
Follow up (all time
points): N/A
End point: 3.87
(0.62)
Attrition details:
Intervention group: 9
dropped out due to
general sickness,
travel or time
constraints.
Control group: 8
dropped out due to
general sickness,
travel or time
constraints.
Baseline
characteristics of
dropouts were
assessed and it was
found that dropout
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
gingival margin)
Time points
measured: Prior to
randomisation and
after 5.5 months
Outcome name:
Gingivitis (T1a and T2)
Outcome definition:
The Dental Gingival
Index (Löe, 1967) is
anchored by scores
ranging from 0
(absence of
inflammation) to 3
(severe inflammation,
marked redness and
hypertrophy; tendency
for spontaneous
bleeding; ulceration.).
An Explorer
Periodontal doubleended Probe LM2352B was used for all
examination
procedures.
Outcome measure:
Index score
Outcome measure
validated: NR
Unit of measurement:
Ranges from 0
(absence of
inflammation) to 3
(severe inflammation,
marked redness and
Results
Notes by review
team
was not due to
baseline or
background
characteristics.
Conclusion:
The current
randomised clinical
trial clearly showed
that a competenceenhancing
intervention, delivered
in an autonomy
supportive manner,
improved motivation,
perceived
competence, dental
health behaviours,
plaque, and gingivitis
relative to standard
care treatment carried
out in an autonomysupportive way.
Combined with a
previous trial by
Halvari and Halvari
(2006), this
emphasises the
importance of dental
professionals relating
to their patients in
autonomy-supportive
and competenceenhancing ways for
patients’ improved
oral health.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
hypertrophy; tendency
for spontaneous
bleeding; ulceration.).
Time points
measured: Prior to
randomisation and
after 5.5 months
Results
Notes by review
team
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any
baseline differences
in important
confounders):
No mention is made of
ITT and the numbers
quoted for the analysis
in Fig 1 exclude the
drop-outs.
Repeated measures
MANOVA was used to
examine the
hypothesis for
perceived dental
competence,
autonomous motivation
for dental home care,
dental behaviour,
plaque and gingivitis at
T1a [baseline] and T2
[5.5 month follow-up],
followed by five
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
repeated measures
ANOVA.
Results
Notes by review
team
For variables that were
measured only one
time, univariate
ANOVAs were used.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Author: David M
O’Hara, Patricia
Seagriff-Curtin,
Mitchell Levitz,
Daniel Davies and
Steven Stock
Source
Population(s):
NR
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): NR
Outcomes (include
details of all relevant
outcome measures
and whether measures
are objective or
subjective or otherwise
validated):
Setting: Specialist
dental clinic (p.150
para.3)
Year: 2008
Citation: O'Hara,
D.M., et al., Using
Personal Digital
Assistants to
improve self-care in
oral health. Journal
of Telemedicine
and Telecare, 2008.
14(3): p. 150-1.
Country of study:
Not stated–
presumably USA
Aim of study: To
evaluate the
potential of
Personal Digital
Assistant (PDA)
technologies to
improve the oral
health of people
with mild to
moderate
intellectual
disabilities, chronic
Location (urban or
rural):NR
Sample
characteristics:
Age: NR
Sex: NR
Sexual orientation:
NR
Disability: All
participants had
intellectual disabilities
and/or chronic health
problems (p.150
para.3)
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
Eligible population
(describe how
Report how confounding
factors were minimised: NR
Programme/Intervention
description:
What was delivered: Oral
health video and audio
materials were prepared that
demonstrated effective oral
hygiene practices. These
materials were edited, digitised
and transferred to PDAs
running a customised software
application that controlled the
standard features of the PDA
so that the prompting and
coaching features only were
enabled. Patients were trained
in the use of the PDAs at a
regular dental appointment and
the alarm and prompting
features of the software were
set to their individual
specifications. (p.140 para.4)
Theoretical basis: The authors
do cite an earlier study which
found that a multimedia training
programme can help adults with
Outcome name:
Change in oral health
status/ utilisation of
PDA
Outcome definition:
Outcome measure:
The utilisation of the
PDA and any change
in oral health status
was tracked by
obtaining anecdotal
information form direct
care support staff
when they brought
patients in for dental
appointments and
when they telephoned
for technical support.
Oral health status was
measured on a 4-point
scale along 12
dimensions including
the overall gingival
colour and texture,
gingival inflammation,
plaque accumulation,
supra and subgingival
Results
Oral health (clinical)
results:
Change in oral health
status:
Ten participants
achieved improvement in
at least three areas of
oral health (no further
details provided) (p.151
para.2)
Behavioural results:
Utilisation of PDA:
The training provided
enabled almost all the
patients to master the
use of the technology
and follow the oral
hygiene instructions
displayed on the PDAs.
However more than half
of the patients reported
problems keeping the
PDAs functioning
properly (mainly keeping
batteries charged) for the
duration of the project.
Attrition details:
11 patients dropped out
of the study.
Notes by review
team
Limitations
identified by author:
NR
Limitations
identified by review
team:
It isn't actually clear
the study was
undertaken in the
USA although the
conclusion and
authorship suggest it
was. The focus is on
patients at a specialist
dental clinic.
Information on
recruitment is limited
and there is no
consideration of
whether this sample is
representative of
other patients
attending specialist
clinics. The study is
only a pilot so it does
not claim to
representative.
While selection of the
eligible population
has a clear rationale it
is not clear how
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Study details
Population and
setting
Method of allocation to
intervention/control
health problems
and a long-standing
history of poor oral
health self-care.
(Summary)
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): Individuals
who had been
receiving regular
dental care from a
single dental practice
specialising in the
care of people with
intellectual disabilities
and chronic health
problems. The study
patients were all on
recall dental visits
every 3 months
because of their poor
oral health. (p.150
para.3)
learning difficulties perform
community-based vocational
tasks (p.150 para 2)
By whom: NR
To whom: 36 patients
How delivered: Training
When/where: Specialist dental
clinic (p.150 para 3)
How often: Once
How long for: Within a day
Study design:
Quantitative Pilot
Evaluation
Quality Score (++,
+, or -): External Validity
(++, +, or -): + That
is the + and borderline however this paper
has considerable
limitations not
covered in this
average score. It
should be noted
that this is only an
explorative study
and the conclusions
should be treated
with extreme
caution.
State if eligible
population is
considered by the
study authors as
representative of
the source
population:
Inclusion Criteria:
All participants had
intellectual disabilities
and/or chronic health
problems (p.150
para.3)
Total sample N = 36
Baseline comparisons (report
any baseline differences
between groups in important
confounders): N/A
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of
analysis
calculus, mouth odour
and extent of tongue
coating (p.150 para.5)
Outcome measure
validated: NR
Unit of
measurement: Score
on a 4 point scale
Time points
measured: This
information was
gathered for a period
of 6 months, which
included 2 dental
visits. At each dental
appointment the same
dentist completed the
multi-item oral health
scale. (p.150 para.5)
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders): NR
(NOTE: this paper was
less than 2 pages long
and gave very little
detail)
Results
Conclusion: The results
of this small pilot project
indicate the potential for
customisable consumer
technologies to improve
self-care among groups
with chronic health
problems. (p.151 para 3)
Our approach addressed
the limitations of current
health promotion
strategies that result from
poor health literacy by
providing alternative
communication strategies
and customised health
education and health
promotion instructions
using
telecommunications
technologies. (p.151 para
4)
Notes by review
team
participants were
selected from within
this population.
Detailed results of the
outcome
measurements were
not given. For
example 10
participants achieved
improvements in at
least 3 areas of oral
health but there is no
information on what
those areas are.
When it came to the
oral health outcome
no other variables
were considered
besides the PDA.
11 patients dropped
out of the study and
there is no information
on whether this was
due to them finding it
difficult to use the
PDA. Baseline
differences in
education and the
level of disability do
not appear to have
been considered.
The sample size is
300
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Exclusion Criteria:
NR
very small (just 36
before attrition).
% of selected
individuals agreed
to participate: NR
Overall this study
should be seen as a
purely exploratory
pilot study – further
research with more
detail would be
needed in order to
generate robust
findings in this area.
Potential sources of
bias:
Evidence gaps: NR
Source of funding:
Partly funded by a
grant from the Joseph
P Kennedy
Foundation.
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
Notes by Review Team
Author: Ostberg, AL
Study design: Qualitative
Research aims, objectives,
and questions:
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Year: 2005
Population the sample was
recruited from: Adolescents
from Skaraborg County,
Sweden; a rural area with a
few medium sized towns and
small municipalities.
The study was carried out in a series
of focus group discussions during
2003-2004. Two gender-specific, and
one mixed-group were created for
each school level, six groups in all.
The groups constituted four to nine
persons sitting around a table – one
group with four, three with five, one
with six, and one with nine
participants. Group size was intended
to be four to six persons. In one
class, however, all boys (nine 15 year
olds) wanted to join the group.
Limitations identified by
review team:
Citation: Ostberg,
AL (2005)
Adolescents’ views
of oral health
education.
Aqualitative study.
Acta Odontologica
Scandinavica, 63:
300-307
Country of study:
Sweden
Quality Score (++,
+, or -) ++
To investigate how
adolescents perceive oral
health education and what
they expect from it. A second
aim was to apply a gender
perspective to the
investigation.
Theoretical approach
[grounded theory, IPA etc]:
Data were analysed according
to the basic principles of the
constant comparative method.
Subsequently data were
interpreted by the author and
repeatedly discussed with a
sociologist who had access to
the entire data set.
State how data were
collected:
What method(s): A series of
focus group discussions; two
gender-specific and one mixed
group were created for each
school level, six groups in
total.
By whom: Discussions were
moderated by the author (a
dentist) who had been trained
in the facilitation of focus
How sample was
recruited: Purposive
sampling through school
nurses in Skaraborg County,
Sweden. The nurses gave
the same information to all
the classes and were
instructed, based on their
knowledge of the students,
to recruit participants who
represented a broad range
of characteristics. All
potential informants were
also given a written invitation
with information about the
study. Letters were sent to
the parents of those under
18 years of age. Written
consent was collected from
the informants and, for the
younger informants, from
their parents.
How many participants
recruited: 34
Sample characteristics:
Age: 14-16 year olds and
18-19 year olds
The discussions were moderated by
the author (a dentist) who had been
trained in the facilitation of focus
groups, and lasted approximately 5070 minutes. An observer with a nondental profession sat to the side to
assist in the note-taking of non-verbal
communication. Before the tape
recorder was turned on, general
information about the study, including
confidentiality and the voluntary
nature of the study, was repeated.
After each session, the observer was
given the opportunity to ask the group
additional questions. Moreover, when
the participants had left the room, the
NR
Data was only collected by
one method although nonverbal responses were
recorded by an observer.
However the methods do
investigate what they claim
to.
Although the contexts of the
data are well described, and
the diversity of perspective
and content was explored,
only the top-level detail and
depth of responses was
analysed and responses
were rarely compared and
contrasted across
groups/sites. However, for
the latter two points, this
may not have been
necessary for the purpose of
this research.
Only one researcher themed
and coded the data,
however they did consult a
sociologist, but there is no
detail about whether the
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Study Details
Research Parameters
groups. An observer with a
non-dental profession sat to
the side to assist in the notetaking of non-verbal
communication.
What setting: Small rooms in
schools. Groups constituted
four to nine persons sitting
around a table
When: Between 2003 and
2004
Population and Sample
Selection
Sex: Both male and female
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Sweden
Occupation:
Education: Senior level and
upper secondary schools
Socioeconomic position:
NR
Social capital: NR
Inclusion criteria: NR
Exclusion criteria: NR
Outcomes and Methods of
Analysis
moderator and the observer
summarised and discussed each
other’s impressions of the session.
When the last focus group session
was completed, no new themes or
data emerged; the saturation point
was considered to have been
reached.
The areas of focus for the group
discussions were the adolescents’ of
the oral health education that they
had experienced in different settings
and under varying circumstances
[only findings pertaining to the dental
practice setting will be reported here].
Typical entry points were as follows:
“When you got this invitation and you
realised that the topic was dental
care, what did you think?”; “When
you last visited the dentist, what
happened? What was it like?”; Where
do you find (health) information about
your teeth and mouth?”
Discussions were tape-recorded and
transcribed verbatim. The author
listened to the tapes and added the
observer’s notes to the transcripts.
Text was initially coded by underlying
substantive words and phrases in
participant statements. Related codes
were grouped in categories. Codes
and categories were continually
compared with the interview
protocols. The commonalities and
contradictions reflected in the data
Notes by Review Team
sociologist's involvement
altered the direction of the
results. It was not reported if
participants fed back on the
data, or if
negative/discrepant results
were addressed or ignored.
There was no discussion of
any of the limitations of the
research.
The study was approved by
an ethics committee but no
other reference to ethics was
given. Consequences were
not considered.
Evidence gaps and/or
recommendations for
future research:
As a growing health concern
in many populations, dietary
issues were not extensively
addressed in this research
and could be explored in
further research.
Source of funding:
The financial support of the
Skaraborg Institute is
gratefully acknowledged.
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
were systematically analysed.
Attempts were made to represent all
the voices in order to cater for the
range in talkativeness and opinions in
the groups.
Notes by Review Team
Key themes and findings relevant
to this review [with illustrative
quotes if available]
In the analysis of the data, two core
categories emerged, giving deeper
understanding of successful oral
health education among adolescents:
“credibility” (the quality, capability, or
power to elicit belief) and
“confidence” (trust or faith in a person
or thing). These two central
phenomena were related to each
other and constantly interacted. The
themes that emerged in the
interviews concerning oral health
education in different settings and
outcomes of such activities were all
related to the two core categories.
Oral health education in the dental
clinic
The amount of information given to
the participants about how to take
care of their teeth and mouth
probably differed. Some considered
the information they had received to
be sufficient, but often the
participants wished to be taught more
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
at the dental visit. Although they can
ask for information, the atmosphere is
often perceived as strict and not
confidential. There are obstacles to
posing questions:
Notes by Review Team
“They say you have forgotten to
brush the back teeth, for instance…
but you cannot ask… How do I brush
them, then? You have to try,
anyhow… you don’t ask much when
you’re there” (Girl, 15 years old)
The way information was given could
be positively perceived, but was often
considered strict and a little dull:
“They are not always good at being
cheerful” (Boy, 19 years old)
Some related positive memories of
receiving information at the dental
services in childhood, in contrast to
the present situation:
“…when I was little… they showed
me how to brush… and that was easy
to understand… like talking to a
child… that was good then. They can
talk if they want to, but otherwise”
(Boy, 19 years old)
Some informants spoke about
occasionally being given oral health
information. The messages from
these occasions were vaguely
remembered. Experiences of
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
instructions in oral hygiene were
mostly positive, and their own
responsibility was acknowledged:
Notes by Review Team
“Anyhow, I think you get clear
information… then it is your own
responsibility to find out…” (Girl, 19
years old)
However there were clear indications
that dental personnel often only
attended to deficiencies in oral
hygiene, whereas good hygiene
rendered few or no comments. When
they received no information, the
adolescents could interpret this as a
sign there was nothing to worry about
and no need to ask:
“I don’t know if they need to give me
information, because I didn’t get any.
I do not think I needed any” (Boy, 19
years old)
Information on the use of floss was
obviously confusing:
“…they keep telling you to floss, yes,
you should do that… but how, no…”
(Girl, 15 years old)
“You get the impression that it’s not
that important then… you should
brush every day, but floss… that’s
something you can do now and
then…” (Girl 15 years old)
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
Dietary advice in the clinical setting
was seldom discussed in any of the
groups. In one group, information in
earlier ages was remembered as “the
usual old stuff”, referring to
restrictions in candy consumption.
Notes by Review Team
The behaviour of the dental
personnel is important for creating a
confidence-building setting, and most
participants had perceived that
treatment was properly carried out.
However, some indicated that they
did not feel they were “heard or
seen”. The dental personnel
sometimes talked about, and not to,
the patients, although they were
present in the room. They were
treated as objects and felt as if the
personnel were “talking over their
heads”.
The quality of the clinical treatment,
such as fillings, was not questioned in
any group. However, the periods
between dental check-ups were
discussed and were often perceived
as too long. Some informants even
thought that they had been forgotten
by the dental services or lost in the
recall system. The main reason for
individualised and extended recall
periods in Swedish dental services
todays – that patients are placed in
different risk categories and the
length of the recall period depends on
the risk category – was not discussed
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
in any of the groups. In two of the
groups (one with younger and one
with older adolescents), distrust was
expressed, and the dental services
were suspected of postponing
treatment until the patients had to pay
themselves (in Sweden from the age
of 20). A credibility gap was created:
Notes by Review Team
“…some people say… that they save
the cavities until you have to
pay…then you panic a little. You feel
that they charge you money, they do
not think of a person’s teeth…” (First
girl, 19 years)
“Yes, I was there some time ago…
they said that I had a small cavity, but
it was too small to fill and that I
should come back next year… I was
very angry and demanded that he fill
it… so I’m going there again to have
it done” (Second girl, 19 years old)
The second girl quoted above was
the only participant who reported a
confrontation with dental personnel.
The pace of work at the dental offices
is often high, and this was noted by
the adolescents:
“You can see that they have a strict
schedule. They have to try and be on
time with their patients… but it is
perhaps not always that good to go
full steam ahead and hope that all will
turn out well… And if you are there
just once a year, it would perhaps be
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
best to take the time to go through it
[the information] properly” (Girl, 15
years old)
Notes by Review Team
The participants were uncertain about
their knowledge of oral health, both
consciously and unconsciously.
Although some considered their own
knowledge to be sufficient in open
statements, the subsequent
discussions exposed uncertainty.
There was a need to get feedback:
“…you don’t know the standard, how
much you should do or what you
should do at all…” (Girl, 15 years old)
The causal relationship between
insufficient approximal hygiene and
gingivitis was not understood by the
informants in any of the groups.
When flossing was practiced, it was
often neglected after a short time:
“It’s too tight, and then you force too
hard… then it starts to bleed…then it
hurts…and then you skip it” (Girl, 15
years old)
“They keep telling me to floss… they
(the teeth) sit so tight together, so it
just bleeds… I think it’s just tiresome”
(Girl, 19 years old)
Thus, even if the informants did
display knowledge of certain oral
health topics, they did not always
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of
Analysis
succeed in practicing healthy habits.
Other activities were often given
priority, especially under time
constraints: “If I am in a hurry in the
morning”.
Notes by Review Team
The need for, and interest in,
knowledge could be projected to
other persons, who were considered
to need it better:
“…more for those who have
problems, they are probably more
interested…” (First boy, 19 years old)
“Yes more…” (Second boy, 19 years
old)
“I don’t often need to go to the
dentist. I only go to the check-ups”
(First boy, 19 years old)
Conclusions:
This study indicates that the
credibility of the people delivering the
health messages is essential, as is
their ability to create confidence
during the encounter in the dental
setting. When oral health education is
perceived to be credible, it generates
confidence. Likewise, when
confidence is perceived, the oral
health messages will be credible.
Thus, oral health education among
adolescents is more likely to be
successful when credibility and
confidence are perceived.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions and
method of analysis
Results
Notes by review
team
Author: Poole, J.,
Conte, C., Brewer,
C., Good, C.,
Perella, D., Rossie,
K. M. and Steen, V.
Source
Population(s):
Country of study
(include if developed
or non-developed)
NR
Method of allocation (describe
how selected individuals/clusters
were allocated to intervention or
control groups – state if not
reported): [quality assessment]
N/A One group pre-post test
design
Outcomes (include details
of all relevant outcome
measures and whether
measures are objective or
subjective or otherwise
validated):
For each outcome
report
Means, SDs, pvalues, CIs, Effect
sizes, SEs
Limitations
identified by
author:
Year: 2010
Setting: NR
Citation: Poole, J.,
Conte, C., Brewer,
C., Good, C.,
Perella, D., Rossie,
K. M. and Steen, V.
(2010) Oral
Hygiene in
scleroderma: the
effectiveness of a
multidisciplinary
intervention
programme,
Disability and
Rehabilitation,
32(5), 379-384.
Country of study:
America
Aim of Study: To
investigate whether
oral hygiene
improves after
persons with
scleroderma
receive structured
Location (urban or
rural): NR
Sample
characteristics:
Age: The mean age
at baseline was 55.4
years of age for
participants with
diffuse scleroderma
and 52.4 years of
age for participants
with limited
scleroderma.
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
NR
Occupation: NR
Education: NR
Socioeconomic
Report how confounding
factors were minimised: N/A –
Before and After Study
Programme/Intervention
description:
What was delivered:
Dental intervention consisted of
dental prophylaxis including
scaling and root planning by a
registered dental hygienist. Each
participant also reviewed a
patient education videotape on
proper brushing and flossing.
Individual instructions to be used
at home were given along with a
6 month supply of dental
products. Occupational therapy
intervention consisted off
participants being shown a video
on hand and facial and oral
augmentation exercises. Each
participant received individual
instructions of exercises to be
performed at home.
Outcome name: Number
of sites bleeding on
probing
Outcome definition:
Number of sites bleeding
on probing
Outcome measure:
Number
Outcome measure
validated: NR
Unit of measurement:
Number
Time points measured:
Baseline, Pre and post
study
Outcome name: Number
of sites with pocket depth
greater or equal to 4mm
Outcome definition:
Number of sites with
pocket depth greater or
equal to 4mm
Outcome measure:
Number
Oral health (clinical)
results:
Intervention group(s):
PHP score
Baseline: Mean=3.3,
SD=0.64
Follow up: Mean=2.9,
SD=0.64
End point: Mean=2.7,
SD=0.51
Intervention group(s):
Number of sites
bleeding on probing
Baseline: Mean=8.5,
SD=21.2
Follow up:
Mean=10.1, SD=14.1
End point: Mean=2.5,
SD=3.7
Intervention group(s):
Number of sites with
pocket depth greater
than or equal to 4mm
Baseline: Mean, 8.0,
SD=15.3
There may have
been observer
differences in
classifying incipient
decay examination.
The subjects were
not contacted on a
regular basis to
ensure compliance
with exercises or
dental programme.
Limitations
identified by
review team:
The source
population is only
partially described.
It is unclear whether
the eligible
population is of the
source population.
Although
participants who
withdrew from the
study were
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Oral Health: Approaches for general practice teams on promoting oral health
oral hygiene
instructions and
facial and hand
exercises.
Study Design: A
one-group pretest/post-test study
design was used for
this study.
Participants were
seen for a baseline
visit (month 0), a
pre-intervention visit
(month 6), and a
post-intervention
visit (month 12).
Quality Score (++,
+, or -): External
Validity(++, +, or ): +
position: NR
Social capital: NR
Eligible population
(describe how
individuals, groups,
or clusters were
recruited, e.g. media
advertisement, class
list, area): Persons
with scleroderma.
Participants were
identified through
the University’s
Systematic Sclerosis
Database
State if eligible
population is
considered by the
study authors as
representative of
the source
population: NR
Inclusion Criteria:
Inclusion criteria
included meeting the
American College of
Rheumatology
[formerly, the
American
Rheumatism
Association] criteria
for definite or
probable systemic
sclerosis
[scleroderma] and
participants had to
Facial grimacing exercises
consisted of 6 exercises
performed in 3 sets of five
stretches, each held for 3–5 s for
example open mouth as wide as
possible.
Oral stretching exercises
consisted of putting the right
thumb in corner of the left side of
the mouth and stretching,
switching thumbs to stretch the
right side of the mouth, and
finally, stretching with both
thumbs at the same time. Then
an oral augmentation exercise
was done by inserting tongue
depressors between the teeth
from the left premolar area to the
right molar region.
The hand exercises consisted of
making a fist, pressing the fingers
flat against each other, and
touching the thumb to the base of
the little finger. These exercises
were performed in 3 sets of 5
stretches, held for 3–5 s, twice a
day.
At baseline, participants received
a dental X-ray, and measures of
oral hygiene and oral aperture,
and dominant upper extremity
functioning that were described
above. 6 months later at the preintervention visit, participants
repeated the same set of
measures at the baseline visit
Outcome measure
validated: NR
Unit of measurement:
Number
Time points measured:
Baseline, Pre and post
study
Outcome name: Number
of teeth with recession
greater than or equal to
3mm
Outcome definition:
Number of teeth with
recession greater than or
equal to 3mm:
measurements of the
recession of the gingival
margin onto the root
surface in millimetres
Outcome measure:
Number
Outcome measure
validated: NR
Unit of measurement:
Number
Time points measured:
Baseline, Pre and post
study
Outcome name: Number
of teeth with supragingival
calculus or subgingival
Follow up: Mean: 7.7,
SD=11.7
End point: Mean=8.9,
SD=11.7
Intervention group(s):
Number of teeth with
recession greater
than or equal to 3mm
Baseline: Mean: 3.0,
SD=2.6
Follow up: Mean=2.6,
SD=4.3
End point: Mean=1.8,
SD=2.7
Intervention group(s):
Number of teeth with
supragingival
calculus
Baseline: Mean=0.27,
SD=0.16
Follow up:
Mean=0.27, SD=0.13
End point:
Mean=0.17, SD=0.87
Intervention group(s):
Number of teeth with
subgingival calculus
Baseline: Mean=0.35,
SD=0.33
Follow up:
Mean=0.37, SD=0.37
End point:
Mean=0.16, SD=0.26
Intervention group(s):
Number of caries
mentioned no
demographic
information was
provided for these
individuals.
It was not reported
whether the setting
in which the study
occurred reflected
usual UK practice.
A control study is
needed in order to
assess the full
impact of these
results.
It was not reported
whether an intention
to treat analysis was
conducted.
Only p-values were
included within the
results section.
No issues were
reported with the
analytical methods
which were chosen.
Intervention effects
were only shown
through p-values.
The results may not
be entirely
generalizable across
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have a minimum of
12 teeth. A minimum
of 12 teeth was
deemed necessary
so that the hygienist
could examine the 6
required teeth on the
Patient Hygiene
Performance Index
or their substitution if
a tooth was missing,
broken, or had a
crown.
Exclusion Criteria:
Participants were
excluded if they
were on
anticoagulation
therapy, had a
diagnosis of
secondary Sjogrens
Syndrome, or lived
outside a 100 mile
radius of the medical
centre.
% of selected
individuals agreed
to participate: 2
participants dropped
out due to
extenuating
personal
circumstances, one
subject dropped out
due to disease
progression, and the
other dropped out
except for the X-ray. At this time,
participants were also given a
customised intervention
programme for both dental
hygiene and upper extremity
function. The intervention lasted 6
months. At the end of the 6
months, at the post-intervention
visit, participants received the
same evaluations (except the Xray) as they had at the preintervention visit.
Theoretical basis: NR
By whom: Dental hygienists
To whom: Participants
How delivered:
Dental history taken and x-ray
PHP Index to measure oral
hygiene
Oral aperture measured
Xerostomia questionnaire for
salivary dysfunction
Measurement of upper extremity
function
Dental prophylaxis
Hygiene instructions and 6 month
supply of dental products
Facial and oral Exercise
instructions at home
Timed dexterity
KT testing
Strength testing
When/where: NR
How often: Baseline, 6 months
and 12 months
How long for: 12 months
calculus
Outcome definition:
Number of teeth with
supragingival calculus.
Number of teeth with
subgingival calculus
Outcome measure: Scale
Outcome measure
validated: NR
Unit of measurement:
0 = absence of calculus
1 = supragingival calculus,
but no subgingival calculus
present
2 = presence of both
supragingival and
subgingival calculus or
presence of subgingival
calculus only
Time points measured:
Baseline, Pre and post
study
Outcome name: Number
of caries
Outcome definition:
Number of decayed,
missing and filled
permanent teeth
Outcome measure:
Number
Outcome measure
validated: NR
Unit of measurement:
Number
Baseline: Mean=0.65,
SD=1.2
Follow up:
Mean=0.24, SD=0.56
End point:
Mean=0.53, SD=1.07
Intervention group(s):
Incisor vertical
distance (mm)
Baseline: Mean=38.5,
SD=6.7
Follow up:
Mean=38.8, SD=7.1
End point:
Mean=39.1, SD=7.8
Intervention group(s):
Lip vertical distance
(mm)
Baseline: Mean=49.1,
SD=7.5
Follow up:
Mean=52.7, SD=7.5
End point:
Mean=48.1, SD=7.3
Intervention group(s):
Xerostomia
Baseline: Mean=1.9,
SD=1.9
Follow up: Mean=1.7,
SD=1.9
End point: Mean=2.2,
SD=2.0
None of the dental
measures changed
significantly from
the source
population.
Evidence gaps:
Future controlled
studies are needed
in which subjects
are randomly
assigned to
intensive treatment
and routine care
groups.
Participants also
need to be followed
and treated over a
longer time period.
To increase sample
size, a multi-centre
study may be
necessary.
Source of funding:
This study was
supported in part by
The Arthritis
Foundation, the
Western
Pennsylvania
Chapter of the
Arthritis Foundation,
and the University of
Pittsburgh Research
Development Fund.
Dental products
were supplied by
CREST, Butler,
Laclede Co., and
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due to recurrent
hospitalisations for
infections.
Potential sources
of bias: NR
Sample size at baseline: 17
Total sample N = 17
Intervention group N = 17
Baseline comparisons (report
any baseline differences between
groups in important confounders):
The final group of 17 participants
consisted of 9 persons (9
females) with diffuse scleroderma
and 8 persons (6 females, 2
males) with limited scleroderma.
The mean age at baseline was
55.4 years of age for participants
with diffuse scleroderma and 52.4
years of age for participants with
limited scleroderma. Mean
disease duration at baseline was
10.5 years for the diffuse
participants and 11.0 years for
those with limited scleroderma.
Study sufficiently powered
(power calculations and provide
details): NR
Time points measured:
Baseline, Pre and post
study
Outcome name: Oral
hygiene
Outcome definition:
Patient Hygiene
Performance Index (PHP)
Outcome measure: 0 to 5
Outcome measure
validated: NR
Unit of measurement: 0
is defined as excellent,
scores 0.1-1.7 are good,
scores of 1.8-3.4 are fair,
and scores of 3.5-5 are
poor.
Time points measured:
Baseline, Pre and post
study
Outcome name: Oral
aperture
Outcome definition: Both
maximum lip and teeth
aperture were measured
with a millimetre ruler. Lip
aperture was measured as
the inner vertical distance
from the bottom of the top
lip to the top of the bottom
lip with mouth open. Teeth
aperture was measured as
the incisal vertical distance
from the bottom of the
baseline to the preintervention visit.
Collis Curve.
There was a
significant difference
in mean PHP scores
and a significant
decrease in the
number of teeth with
supragingival
calculus from the
baseline to postintervention, p<.05.
The PHP scores did
not significantly
improve from preintervention to postintervention.
Dental measures
decreased or
improved from the
pre-intervention to
post-intervention visit
but the only
significant decreases
were in the number of
sites that bled on
probing and the
number of teeth with
supragingival
calculus p<.05.
The number of caries
increased as did the
number of sites with
pocket depths of >4
cm.
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maxillary incisors to the
top of the mandibular
incisors with the mouth
open
Outcome measure:
millimetres
Outcome measure
validated: NR
Unit of measurement:
millimetres
Time points measured:
Baseline, Pre and post
study
Outcome name:
Xerostomia
Outcome definition: 9
item questionnaire to
assess the presence of
salivary dysfunction
Outcome measure: 2
point scale Yes or No
Outcome measure
validated: NR
Unit of measurement:
Yes (1) or no (0) and then
summed to yield a total
score from 0 to 9.
Time points measured:
Baseline, Pre and post
study
Outcome name:
Dominant upper extremity
function
Behavioural results:
N/A
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control)
2 participants
dropped out due to
extenuating personal
circumstances, one
subject dropped out
due to disease
progression, and the
other dropped out
due to recurrent
hospitalisations for
infections.
Conclusion: The
results suggest that
the intervention home
programme improved
oral hygiene. The
number of sites
bleeding on probing
and the number of
teeth with
supragingival
calculus decreased
significantly and there
was a definite trend
toward improvement
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Oral Health: Approaches for general practice teams on promoting oral health
Outcome definition:
Measurements of the
upper extremity function
included range of motion,
grip and pinch strength,
and dexterity. The upper
extremity items from the
Keital Function Test (KT),
which consists of 11
performance tasks such as
making a fist, touching
hands to shoulders and
behind the neck, was used
to measure active range of
motion. Scores range from
0 to 26 for each upper
extremity, low scores
indicate decreased joint
motion. Interobserver
agreement was reported
as 0.85 and test–retest
reliability as 0.96.
Outcome measure: 0 to
26
Outcome measure
validated: NR
Unit of measurement: 0
to 26
Time points measured:
Baseline, Pre and post
study
Outcome name: Grip
Strength
Outcome definition: Grip
strength was measured
using a vigorimeter and
in the other
measures.
The number of sites
with pocket depths
and the number of
caries increased from
pre- to post
intervention. A
controlled study
design would be
needed to determine
whether there was
any relationship
between periodontal
carries and disease
progression.
Oral exercises and
education regarding
proper dental care
may be useful in
managing oral
hygiene in persons
with scleroderma.
Persons with
scleroderma should
have regular dental
check-ups, cleanings
and specific
instructions regarding
difficulties with
brushing or flossing
their teeth.
Decreased oral
aperture and upper
extremity function are
related to oral
hygiene. Extensive
316
Oral Health: Approaches for general practice teams on promoting oral health
lateral pinch and palmer
pinch were measured with
a pinchmeter. The average
of 3 consecutive
measurements for the
dominant hand for these
tests used.
Outcome measure:
Strength = kp
Vigorimeter and
pinchmeter = kg
Outcome measure
validated: NR
physical and
occupational therapy
exercises are also
needed early after
diagnosis to maintain
hand and mouth
motion and hand
dexterity in order to
maintain oral health.
Unit of measurement:
Strength = kp
Vigorimeter and
pinchmeter = kg
Time points measured:
Baseline, Pre and post
study
Outcome name: Dexterity
Outcome definition:
Timed button test,
Backman et al (1991) and
Grooved Pegboard, Trites
(1977).
The timed button test
consists of buttoning and
unbuttoning five 5/8 inch
buttons [19]. For the
Grooved Pegboard, pegs
which have a key along
each side are rotated in
order to be inserted in a
pegboard with randomly
positioned slots [20]. The
317
Oral Health: Approaches for general practice teams on promoting oral health
score is the time it takes to
insert the 25 pegs.
Outcome measure:
Timed button test –
buttoning/unbuttoning 5/8
inch buttons
Grooved peg board –
randomly positioned slots
Outcome measure
validated: NR
Unit of measurement:
Speed
Time points measured:
Baseline, Pre and post
study
Method of analysis
(indicate if ITT or
completer analysis was
used and if adjustments
were made for any
baseline differences in
important confounders): Ttests were used to
compare baseline, pre and
post-intervention dental
and upper extremity
measurements.
Correlations were
performed using the
Pearson correlation
coefficient. A p-value of
<.0.05 was chosen as
statistically significant.
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: Serena
Rajabiun,
Jane E. Fox,
Amanda McCluskey,
Ernesto Guevarac,
Niko Verdecias,
Yves Jeanty,
Michael DeMayo,
Mahyar Mofidi,
Study design: The study
was designed to interview
participants at the initial
receipt of dental care and
approximately 12–15 months
later to ascertain participants’
perceptions of the
programme and its effect on
their self-care practices, as
well as their desire to come
back for care. An openended interview guide was
used to capture participant
perceptions and experiences
in their own words. (p.75
para.2)
Population the sample was
recruited from: An initial
subsample of 60 participants
was recruited from a national
study of HIV-positive patients
enrolled in the Oral Health
Initiative. (p.75 para.1)
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author:
Year: 2012
Citation: Rajabiun,
S., et al., Patient
perspectives on
improving oral
health-care practices
among people living
with HIV/AIDS.
Public Health
Reports, 2012.
127(SUPPL.2): p.
73-81.
Country of study:
USA
Quality Score (++,
+, or -) +
Research aims, objectives,
and questions:
The purpose of this
qualitative study was to
explore the knowledge,
attitudes, and practices of
oral health care among
PLWHA that may contribute
to the access to and use of
dental care services. (p.74
para.3)
Theoretical approach
[grounded theory, IPA etc]:
N/A.
State how data were
collected:
What method(s): Each site
How sample was recruited:
Six study sites (two rural and
four urban) volunteered to
recruit eight to 10 participants
each for the study.
Participants were selected to
reflect each site’s patient
demographic distribution.
(p.75 para.1)
How many participants
recruited: 39 (p.75 para.4)
Sample characteristics:
Age: mean was 46.5 years
(range: 29-67 years)
Sex: Male=30 Female=9
Sexual orientation: NR
Disability: All patients had
HIV
Ethnicity: Majority from
ethnic minority groups
(African American/black=14;
Hispanic=6; Asian or Native
American=3)
Religion: NR
Place of residence: NR
Occupation: NR
The initial interview focussed on prior
experience with oral health care since
childhood and pre and post-HIV
diagnosis. This assessed personal
values, knowledge, and practices, our
questions included the following. (p.75
para.2)
At the follow-up interview, participants
were asked: (1) What information did
you learn from participating in the Oral
Health Initiative program? (2) What
changes have you made with respect
to taking care of your mouth, teeth,
and gums (your oral health habits)
since your first dental care visit with
our programme? (3) What factors
have made the biggest difference in
your self-care practices? Interviews
were conducted in English and
Spanish. All interviews were recorded
and transcribed for coding and
analysis. (p.75 para.2)
Thematic analysis was used to
identify and report patterns within the
data.19 Relevant themes emerged
based on frequency of discussion and
expression of importance by
participants. The researchers at the
participating sites and multisite
Our study consisted of a
small sample of PLWHA
who had access to and the
opportunity for continuous
dental care and treatment.
The results represent the
attitudes and perceptions of
a small group; nonetheless,
we believe they may be
widespread among PLWHA.
Second, our study was
based on interviews and
self-reported changes and
was not designed to
conduct observations of
patient practices. There is a
possibility that the
participants may have
provided more positive
feedback about participating
in the programme in an
effort to ensure
sustainability for dental
services; however, asking
open-ended questions to
describe their knowledge,
attitudes, and practices
allowed for more in-depth
responses that were
trustworthy and reliable.
(p.80 para.2)
Limitations identified by
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
implemented a programme
intervention to improve
access to and use of dental
services for PLWHA.
Interventions included using
dental care coordinators,
improving coordination with
HIV medical care, providing
transportation assistance,
enhancing patient education,
and setting up mobile dental
units. (p.75 para.1)
By whom: Oral Health
Initiative – more specific
information is not provided
What setting: Oral Health
Initiative sites
When: NR
Population and Sample
Selection
Education: NR
Socioeconomic position:
NR
Social capital: NR
NOTE: 21 respondents did
not return for a follow-up
interview. (p.75 para 4)
Inclusion criteria: All
participants had been out of
dental care for at least one
year and were recently
enrolled in dental care at the
Oral Health Initiative sites.
(p.75 para 1)
Exclusion criteria: NR
Outcomes and Methods of Analysis
Notes by Review Team
research centre read each transcript
and developed an initial list of codes
representing these themes. The
coding list was used to assign
segments of the narrative data at both
initial and follow-up interviews. To
assess knowledge and practices,
participant responses were compared
with the American Dental
Association’s (ADA’s) recommended
care practices for the general
consumer. 2 researchers at the
multisite centre checked and validated
the interpretations of the data. Final
selection of the narrative data was
conducted by the primary researchers
at the multisite research centre and
shared with the researchers at the
sites for accuracy in reporting results.
(p.75 para.3)
review team:
Key themes and findings relevant
to this review [with illustrative
quotes if available]
Baseline:
1) Limited knowledge and practice
of oral hygiene
In general participants had limited
understanding of appropriate oral
hygiene practices in comparison
with the American Dental
Association’s recommended
practices. Few participants were
able to describe recommended
frequency for brushing and
The sample size is small
and unlikely to be
representative, and the
qualitative study used does
provide an element of depth
which would be lacking in a
quantitative study. However
given that the study had a
baseline and a follow-up
and that some of the
findings at follow-up stage
apparently related to
improvement in oral health
the addition of a quantitative
element could have
enhanced this study. At a
minimum some quantitative
data on exactly which
participants reported which
changes would have been
useful. This does not,
however, detract from the
value of the qualitative data
provided.
The aim of the study was to
explore knowledge,
attitudes and practices
amongst of oral health care
among PLWHA but the
actual focus of the study is
on an intervention for this
group and its impact.
Some attempt was made to
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
flossing and only eight were able
to describe regularly going to the
dentist. Only 2 participants
reported avoiding alcoholic
mouthwash and using fluoride
rinses. (p.76 para.2)
2) Attitudes towards the
importance of dental care.
Participants with a positive
attitude towards dental care were
influenced by concerns around:
oral infections related to HIV;
appearance; and/or employment
opportunities (p.86 para.3).
Impact of participation in the Oral
Health Initiative:
1) Awareness of the link between
HIV health and good oral health
Participants described gaining
knowledge about sound oral
health-care practices as part of
overall HIV care. Others found it
helped them to eat more and feel
healthier with HIV. (p.77 para.2)
2) Better hygiene practices
Several participants described
how they brush and floss with
improved technique and greater
frequency. Some cited positive
changes in their diet but
knowledge of the detrimental
effects of smoking did not lead
people to stop the habit. (p.77
paras.3-4)
Notes by Review Team
get a range of different
respondent demographics in
the sampling. Recruitment
was from an initial subsample from a national
study and this may have
biased the responses.
The interviews are
described in detail with
example questions.
Additional quantitative data
on oral care habits (e.g.
number of times brushing
teeth) might have been
useful.
There is insufficient
information on how the
research was explained to
participants.
Participants' characteristics
are given. The effect of the
interviewer in terms of
encouraging positive
responses to oral health
intentions does not appear
to have been considered.
Only one method was used
and some triangulation
could have been made e.g.
with number of visits to the
clinic or even with oral
health improvements.
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
3) Improved self-esteem and
appearance
Participants reported feeling less
self-conscious and more confident
in their social interactions (p.77
para.5)
4) Relief of pain and better
physical and emotional health
(p.77 para.7)]
5) Reasons for returning to dental
care
For almost all participants the Orla
Health Initiative made it possible
to “have a place to go for care”.
Participants cited the free or
limited costs of the services as
reasons for returning. (p.77
para.8)
6) Friendly staff and dental
environment (p.77 para.9)
7) Finding and HIV knowledgeable
dentist (p.77 para.11)
8) Having a care coordinator to
educate and support dental
care
4 of the sites employed dental
care coordinators, staff who
worked as either HIV case
managers or patients navigators
to tend to clients’ specific needs.
As well as encouraging patients to
Notes by Review Team
2 researchers at the
multisite centre checked
and "validated" the
interpretations of the data. It
is not clear whether any of
these researchers had done
any of the initial coding and if so how this was
checked.
Reporting by theme is
clearly laid out. Some
figures for response
numbers would have been
useful.
Ethics doesn't appear to be
mentioned - yet these are
potentially vulnerable adults.
This does not mean an
ethics form was not
submitted but it would be
useful if some information
on the ethical protocol was
given.
Evidence gaps and/or
recommendations for
future research: NR
Source of funding: This
study was supported by
grant #H97HA07519 from
the U.S. Department of
Health and Human
Services, Health Resources
and Services
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
return to care these coordinators
played a role in patient education.
Participants described how the
staff member took the time to
explain how to take care of the
mouth and teeth. The care
coordinator could answer the
questions and educate and
reinforce messaged shared by
other dental staff (p.78 paras 3
and 6)
Notes by Review Team
Administration. This grant is
funded through the
HIV/AIDS Bureau’s Special
Projects of National
Significance program. (page
80 footnote)
9) Maintaining personal oral
health and overall oral health
Another motivating factor for
coming back into dental care was
maintaining oral health and overall
general health. For some the
desire to maintain their oral health
was also linked to their HIV
health. (p.78 para.8)
Conclusions:
This qualitative study provides indepth information about the personal
values and practices that can
influence oral health-care-seeking
behaviour among PLWHA. The
results highlight a need for strategies
that focus on the importance of oral
health in the context of HIV health and
provide information about and
demonstration of appropriate self-care
techniques. HIV and dental
professionals can also play a critical
role by establishing a friendly dental
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
setting that fosters trust, support, and
education to encourage the adoption
of healthy behaviours. (p.80 para.3)
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Study details
Population and setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
Author: A
Sbaraini and
RW Evans
Source Population(s):
Sydney, Australia – but no further
information on source population
Limitations
identified by
author:
Setting: a caries management clinic was
established in the General Practice
Department, at the Westmead Centre for
Oral Health (p.341 para.2 and 3) NOTE:
Some concerns about whether this is an
eligible dental clinic however their website
notes that it is: “is the provider of general
dental services to the eligible population
of the Western Sydney Local Health
District.”
(http://www.wslhd.health.nsw.gov.au/OralHealth)
Outcomes (include
details of all
relevant outcome
measures and
whether measures
are objective or
subjective or
otherwise
validated):
Status of nonproximal
surfaces
Year: 2008
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): During the first
oral hygiene coaching
session, patients were asked
informally whether they
would be willing to
commence daily
toothbrushing and continue
to do so during the audit
period. Patients who
indicated willingness were
classified as ready to change
(RTC) their oral behaviour or
otherwise not ready (p.341
para.11 to p.342 para.1)
[NOTE: the RTC group is not
an intervention group – both
RTC and non RTC received
the intervention]
At baseline, 142
tooth surfaces
presented with
large opaque
white spots but
100 of them were
arrested and
appeared as shiny
white spots after
six months. Also,
at baseline, there
were 228 softbased cavities of
which 137 were
temporarily
restored with
glass ionomer
cement (GIC)
(Fuji7). None of
the GIC
restorations
presented with
recurrent caries
after 6 months. All
24 other
softbased cavities
became hard and
black after 6
months following
the fluoride
It was not
practical for the
Researcher ⁄
Operator to be
blinded to the
clinical findings at
the 6-month
follow-up and,
therefore, to
contribute to the
reduction in
measurement
bias. However,
the follow-up
bitewing
radiographs were
read without
reference to the
baseline readings
and other clinical
diagnostic criteria
used were clearcut. Hence, it is
unlikely that the
main study
findings have
been unduly
biased. The
findings presented
here refer only to
Citation:
Sbaraini, A. and
R.W. Evans,
Caries risk
reduction in
patients
attending a
caries
management
clinic. Australian
Dental Journal,
2008. 53(4): p.
340-8.
Country of
study: Australia
Aim of Study:
The hypothesis
to be tested was
that the high risk
of caries in
patients
receiving
treatment in the
Caries
Management
Clinic (CMC)
Location (urban or rural): Urban
Sample characteristics:
Age: 18-35 years
Sex: NR
Sexual orientation: NR
Disability: 3 (7%) of patients had a
mental health condition (p.344 Table 2)
Ethnicity: NR
Religion: NR
Place of residence: NR
Occupation: NR
Education: NR
Socioeconomic position: NR
Social capital: NR
Eligible population (describe how
Report how confounding
factors were minimised:
Programme/Intervention
description:
What was delivered: Phase
1: Patients attended a
baseline assessment which
included measurements for
gingival status and caries
Outcome name:
Status of nonproximal surfaces
Outcome
definition: Surface
status based on
different
categories: sound;
sealed; filled and
sound; shiny white
spot; opaque white
spot; hard-based
cavity; soft-based
cavity (p.346 Table
5)
Outcome
measure:
Radiography
Outcome
measure
validated: NR –
but intra-examiner
reliability was
tested with kappa
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Study details
Population and setting
Method of allocation to
intervention/control
according to the
Caries
Management
System
Protocols
(CMS). (p.341
para.3)
individuals, groups, or clusters were
recruited, e.g. media advertisement, class
list, area): High risk male and female
patients not limited to but including
cigarette smokers, methamphetamine
users, and other drug addicted patients,
aged 18-35 years were referred to this
clinic from other Hospital Departments
(but see note above on setting). (p.341
para.5)
status. At the second
appointment patients
received a dental case
presentation which included
a dental caries education
leaflet. Most importantly they
were informed that tooth
decay can be stopped,
prevented and reversed.
Results of the bitewing
radiograph analysis were
recorded on the pamphlet. In
some caes oral hygiene
instruction commenced at
the baseline clinical
examination rather than the
second appointment. (p.341
(para10) to 342 (paras2-5).
Study Design:
Before and After
Intervention
Study
Quality Score
(++, +, or -): External
Validity(++, +,
or -): +
State if eligible population is
considered by the study authors as
representative of the source
population: NR (there is insufficient
information on the source population)
Inclusion Criteria: NR
Exclusion Criteria: NR
% of selected individuals agreed to
participate: NR
Potential sources of bias: NR
The dentist gave a chairside
demonstration of plaque
around the gingival margin
and oral hygiene instruction
and further toothbrush
coaching took place in a
separate room – the ‘oral
hygiene bay’. At the first
coaching session patients
demonstrated how they
brushed and the both the
dentist and patient reviewed
performance against the
leaflet – the patient then
practised new movements in
front of a mirror (p.343 paras
Outcome
definitions and
method of
analysis
values (p.343 para
11)
Unit of
measurement:
Number and
percentage of
surfaces remaining
unchanged from
baseline
Time points
measured:
Baseline and 6
months
Outcome name:
Status of proximal
surfaces
Outcome
definition: Surface
status based on
different
categories: sound;
sealed; filled and
sound; shiny white
spot; opaque white
spot; hard-based
cavity; soft-based
cavity (p.346 Table
6)
Outcome
measure:
Radiography
Outcome
Results
Notes by review
team
varnish treatment.
9 opaque white
spots, 1 sealed
surface, and 2
sound surfaces at
baseline
progressed to
soft-based
cavities after 6
months. (p. 354
(para 1) to 346
(para 1)
patients who
returned for dental
care; they are not
calculated on an
‘intention to treat’
basis. Therefore,
they may be
generalised to
indicate potential
outcomes for
patients who are
prepared to return
for ongoing
preventive care.
(p.348 para 2)
Status of
Proximal
Surfaces
At baseline, 683
proximal surfaces
were sound, and
95% of them
remained sound
after 6 months. 3
surfaces became
associated with
new
radiolucencies
following baseline,
2 of which had
progressed to
dentine. 19 sound
surfaces, at
baseline,
belonged to
impacted third
Limitations
identified by
review team:
Demographics of
source population
not reported.,
therefore cannot
determine if
eligible population
is representative
of source
population. More
than 20% dropped
out – should have
been dealt with
with ITT.
Evidence gaps:
NR
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Study details
Population and setting
Method of allocation to
intervention/control
1-2)
Patients were given a tube of
toothpaste and, if needed,
chlorofluor gel. Use of these
kits was monitored at
subsequent visits as patients
were requested to bring
them in (p.343 para.3)
Topical applications of
fluoride varnish commenced
in Phase 1 and occurred
every 2 weeks during phase
2 (p.343 para.4)
Phase 2: A monitoring phase
of 3 months – oral hygiene
sessions were reviewed
every 2 weeks at coaching
sessions for toothbrushing,
(p.343 para.6)
Phase 3: 3 months trial –
patients were not recalled
but advised beforehand to
follow the home care
instructions – a reward for
effective maintenance during
trial phase was the promise
of replacing pink GIV
temporary fillings with tooth
coloured restorations. (p.343
para.7)
Outcome
definitions and
method of
analysis
measure
validated: NR –
but intra-examiner
reliability was
tested with kappa
values (p.343
para.11)
Unit of
measurement:
Number and
percentage of
surfaces remaining
unchanged from
baseline
Time points
measured:
Baseline and 6
months
Outcome name:
Dietary habits
Outcome
definition: Not
completely clear
but relates to
consumption of soft
drinks, sugar in tea
and coffee and
chewing sugar free
gum
Outcome
measure:NR
Outcome
Results
molars or teeth
that had advanced
caries on other
surfaces and were
later extracted.
None of the
patients presented
with retained
roots.(p.346
para.2)
Notes by review
team
Source of
funding:
Received support
from GC
(Australia)
At baseline, 683
proximal surfaces
were sound, and
95% of them
remained sound
after 6 months. 3
surfaces became
associated with
new
radiolucencies
following baseline,
2 of which had
progressed
to dentine.
Nineteen sound
surfaces, at
baseline,
belonged to
impacted third
molars or teeth
that had advanced
caries on other
surfaces and were
later extracted.
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Study details
Population and setting
Method of allocation to
intervention/control
Phase 4: Follow-up after 6
months – patients were
recalled for clinical and
radiographic examinations.
Theoretical basis: N/A
By whom: Dentist
To whom: All patients –
including RTC and nonRTC
How delivered: See above
When/where: Dental clinic
How often: Varies by phase
– see above
How long for: No detail on
length of phase 1 but phase
2-4 covered a 6 months
period in total.
Outcome
definitions and
method of
analysis
measure
validated: NR
Unit of
measurement:
Appears to vary
depending on
specific dietary
habit
Time points
measured:
Baseline and 6
months
Total sample N = 45
(referred to CMC during
2005) (p.343 para.12)
Ready to Change N = 16
Non RTC N= 29 (p.244
para.5)
Method of
analysis (indicate
if ITT or completer
analysis was used
and if adjustments
were made for any
baseline
differences in
important
confounders):
Baseline comparisons
(report any baseline
differences between groups
in important confounders):
RTC patients were more
than twice as likely to have
fewer sites scored GI-2
(RR=2/.43, 95% CI (1.24,
4.71) p=0.01) (p.344 para.5)
Data analysis
included the
assessment of
changes from
baseline till the 6month follow-up of
Gingival Index
scores, caries
clinical findings,
Sample size at baseline:
Results
Notes by review
team
None of the
patients presented
with retained
roots. (p.346
para.2)
Dietary Habits:
In general, the
patients were
unable to change
their dietary
habits. It was
reported by many
that they
continued to have
up to 3 teaspoons
of sugar in
coffee or tea, or to
keep drinking soft
drinks during the
day, even bringing
soft drinks with
them to their
dental
appointments.
(p.346 para.3)
Conclusion:
This study
demonstrated that
a non-invasive
caries
management
protocol for 6
sessions
328
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and setting
Method of allocation to
intervention/control
Study sufficiently powered
(power calculations and
provide details): It was
anticipated that 50 patients
would be recruited during the
audit period. Based on a
significance level of 0.05 a
sample of 17 subjects would
provide 80% power to detect
a 30% reduction in the total
Gingival Index score with
95% confidence (2 tailed
comparison) (p.341 para.6)
Outcome
definitions and
method of
analysis
and bitewings
radiographs
scores. Differences
in proportions were
tested using the
Chi-squared test
and Fisher’s Exact
Test for categorical
variables. The data
analysis was
conducted using
both SPSS 15.0
and Epi info
3.2.2software.
Diagnostic
reliability of
bitewing
radiolucency
assessment was
determined by
means of the
Kappa
statistic.(p.343
para.10)
Results
Notes by review
team
conducted every 2
weeks which
combined (1)
professional
applications of
topical fluoride
varnish; (2)
intensive coaching
and monitoring of
toothbrushing
performance; (3)
home care using
5000 ppm
strength fluoride
toothpaste; and
(4) chlorhexidine
gel in a group of
high caries risk
patients enabled
these patients to
attain and
maintain low
plaque levels,
decrease gingival
inflammation, and
reduce caries
incidence and
progression.
(p.347 para.2)
Within a matter of
weeks, factors
that have a
bearing on the
creation of a
329
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
favourable oral
environment can
be activated and
result in
substantial
reductions in risk
of caries
incidence and
progression. This
favourable
outcome occurred
in patients who,
prior to their entry
to the CMC, were
very high risk. It is
reasonable to
conclude,
therefore, that the
adoption of this
approach to caries
management
more generally
would sharply
decrease caries
incidence and
prevalence in the
population. (p.348
para.3)
330
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author: Schouten, B.
C., Eijkman, M.A.J.,
and Hoogstraten, J.
Source
Population(s):
Country of study
(include if developed
or non-developed)
Netherlands (p11,
para.4).
Method of allocation
(describe how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): [quality
assessment] N/A
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
For each outcome
report:
Means, SDs, p-values,
CIs, Effect sizes, SEs
Limitations identified
by author:
Setting: In the dental
examination room and
the waiting room of
their usual dental
practice. (p12,
para.3).
Report how confounding
factors were minimised:
[quality assessment] NR
Year: 2003
Citation: Schouten,
B. C., Eijkman,
M.A.J., and
Hoogstraten, J.
(2003) Dentists’ and
patients’
communicative
behaviour and their
satisfaction with the
dental encounter,
Community Dental
Health, 20, 11-15.
Country of study:
Netherlands
Aim of Study: To
examine the relations
between patients’ and
dentists’
communicative
behaviour and their
satisfaction with the
dental encounter.
(p11, para.3).
Study Design:
Patients were
observed through
Location (urban or
rural): NR
Sample
characteristics:
Age: 17-72 years
(mean 38.6) (p.12,
para.2).
Sex: 49 male, 41
female (p.12, para.2).
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
Netherlands (p.11,
para.4).
Occupation: NR
Education: NR
Theoretical basis:
In line with previous findings
it was hypothesised that
more active patients are less
satisfied with the
communicative behaviour of
the dentists but more
satisfied with their own
communicative behaviour
than more passive patients.
In addition, it was expected
that patient satisfaction with
consultations was
determined more strongly by
the communicative behaviour
of the dentists than by their
own communicative
behaviour. Furthermore it
was hypothesised that
dentists’ satisfaction with
consultations would be lower
than interacting with more
active patients than with
Outcome name:
Satisfaction of dentist
and patient. (p13,
para.2).
Outcome definition:
How satisfied the
dentist was with how
the consultation with
the patient went. A
general satisfaction
item was also added.
(p12, para.4).
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of measurement:
5 point Likert-scale,
ranging from 1 (totally
disagree) to 5 (totally
agree). General
satisfaction item: 1
(totally unsatisfied) to 5
(totally satisfied). (p12,
para.4-5).
Time points
Oral health (clinical)
results: N/A
The nature and size of
the study sample limits
the generalisability of
the results. (p.14,
para.6).
Behavioural results:
Intervention group(s):
Satisfaction of dentist
and patient.
Baseline: N/A
Follow up (all time
points): N/A
End point: The mean
score on the dentists’
satisfaction scale was
33.9 (SD 5.04, range 540). The mean score on
items regarding the
satisfaction with
dentists’ own behaviour
was slightly, though
significant, higher than
the mean score on
items regarding
dentists’ satisfaction
with the behaviour of
the patient. (paired ttest, t=3.9, p<.001).
Mean score on the
general satisfaction
item was 4.4 (SD 0.68,
Limitations identified
by review team:
The source population
is not very well
described.
It is impossible to say
whether the eligible
population represents
the source population.
It is not clear how
selection bias
minimised as the
sample was of patients
visiting the dentists for
emergency treatment
in different locations. It
is possible that
selection on particular
days may have led to
bias.
The authors only
partially explained the
331
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
their dental
examination, they
were visiting the
dental practice for
emergency treatment.
They were then
asked to fill out a
questionnaire in the
waiting room
assessing their
satisfaction with the
dental encounter as
well as a few other
questions regarding
their visit. The
dentists also filled out
a short questionnaire
assessing their
satisfaction after each
consultation. (p12,
para.3).
Socioeconomic
position: NR
Social capital: NR
more passive ones. (p.11
para 3)
Quality Score (++, +,
or -): External Validity(++,
+, or -): -
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): Patients
visiting the practice for
emergency treatment.
(p.12, para.1).
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR
Inclusion Criteria:
Patients had to be
older than 16 and had
to be able to speak
and read the Dutch
language. Had to be
visiting the dental
practice for
emergency treatment.
(p.12, para.1).
Exclusion Criteria:
What was delivered:
In the dental examination
room, a video camera was
placed in the corner, which
recorded the patients from
the moment that they
entered the room to the
moment which they left. After
the conclusion of the
consultation the patients
filled out a questionnaire in
the waiting room assessing
their satisfaction with the
dental encounter as well as
several other variables,
including their age, gender
and education, the reason for
their visit, the perceived
invasiveness of the
treatment, the perceived
health of the teeth, if the
patient had visited their own
dentist in the past twelve
months and if they could
afford financially the
(proposed) dental treatment.
(p12, pa. 3).
The dentist also filled out a
short questionnaire
assessing their satisfaction
after each consultation.
Outcome definitions
and method of
analysis
measured: At the end
of the consultation.
(p12, pa.3).
Outcome name:
Communicative
behaviour of dentist
and patient. (p13, pa.4).
Outcome definition:
Patient’s informationseeking behaviour,
patient participation in
dental decision-making,
whether patients had
requested a specific
treatment, whether
patients had proposed
an alternative treatment
and who made the
ultimate decision.
Dentist’s
communicative
behaviour was measure
using an adaption of
the communication in
dental settings scale
(CDSS). (p12, pa.6-8).
Outcome measure:
Observation
Outcome measure
validated:
Patients’ informationseeking behaviour:
Mean interraterreliability was 0.74
(range 0.59-0.95).
Results
Notes by review team
range 1-5) and
correlation between the
total scale score and
the general item score
was Pearson’s r = 0.48
(p<.001). (p13, para.2).
selection of the
variables included.
Total score on the scale
assessing patients’
satisfaction was 78.6
(SD 9.0, range 19-95).
The mean score
regarding the
satisfaction of patients
with the dentists’
communicative
behaviour was
significantly higher than
the mean score
regarding their
satisfaction with their
own communicative
behaviour (paired t-test,
t=6.3, p<.001). (p13,
pa.3).
Mean score on the
general satisfaction
item was 4.6 (SD 0.83,
range 1-5) and the
correlation between the
total scale score and
the general item score
was Pearson’s e =0.51,
p<.001). (p13, pa. 3).
The authors do not
report how they
controlled for
confounding variables.
It is not reported how
well this setting
reflects a usual UK
dental setting.
No baseline measure
of the individuals
attitudes towards their
dental encounter is
taken before their
consultation.
Only the p-values are
reported, no
confidence intervals
are reported.
Dental emergencies
have been used that
might not reflect the
typical feelings of
someone who visits for
a general check-up.
Evidence gaps: NR
Source of funding:
332
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Study details
Population and
setting
Method of allocation to
intervention/control
% of selected
individuals agreed
to participate: 10 out
of the 119 patients
approached declined
to participation within
the study. 6 patients
initially agreed but
failed to complete the
post-appointment
questionnaire. 13
recordings were
unusable due to their
lack of quality. (p.12,
para.2).
By whom: Dentist
To whom: Patient
How delivered: Videorecordings and a
questionnaire.
When/where: Upon a visit to
a dental practice for
emergency treatment.
How often: Once
How long for: Once
Potential sources of
bias: NR
Sample size at baseline:
N/A
Total sample N = 90
patients
Intervention group N = N/A
Control Group N = N/A
Baseline comparisons
(report any baseline
differences between groups
in important confounders):
N/A
Study sufficiently powered
(power calculations and
provide details): NR
Outcome definitions
and method of
analysis
Mean intraraterreliability was 0.82
(range 0.63-0.94). (p12,
para.6).
Patient participation in
dental decision-making:
Mean interraterreliability was 0.80;
range intrarater
reliability: 0.84-0.95).
(p12, para.7).
Whether patients had
requested a specific
treatment: Mean
interrater-reliability was
0.87; range intrarater
reliability: 1). (p12,
para.7).
Whether patients had
proposed alternative
treatment options:
Mean interraterreliability was 0.96;
range intrarater
reliability: 0.95). (p12,
para.7).
Who made the ultimate
decision: Mean
interrater-reliability was
0.65; range intrarater
reliability: 0.63-0.68).
(p12, para.7).
Results
Notes by review team
Older patients were
somewhat more
satisfied than younger
patients (r=0.27,
p<.011). Correlation
coefficients between the
different scores
assessing patients’
satisfaction and
dentists’ satisfaction
showed that these 2
variables were
unrelated (range 0.003
– 0.09). (p13, para.3).
NR
Intervention group(s):
Communicative
behaviour of dentist
and patient.
Baseline: N/A
Follow up (all time
points): N/A
End point: Mean score
on the CDSS was 9.6
(SD3.1, scale range 0 –
21). (p13, para.4).
Background variables
significantly associated
with dentists’
communicative
behaviour were
dentists’ age (r=0.21,
p=.048) and the number
of patients visiting them
at least once a year
333
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
CDSS: Mean interraterreliability using Cohen’s
Kappa was 0.62; range
intrarater reliability:
0.62-0.73). (p12,
para.8).
Unit of measurement:
Patients’ informationseeking behaviour:
Number and nature of
questions asked. (p12,
para.6).
Patient participation in
dental decision-making:
Recording whether
patients chose to selfdiagnose. (p12, para.7).
Whether patients had
proposed alternative
treatment options:
Recording any
alternatives that were
raised. (p12, para.7).
Who made the ultimate
decision: either the
dentist or the patient.
(p12, para.7).
CDSS: rated at 0 for
poor, 1 for acceptable,
2 for acceptable and 3
Results
Notes by review team
(r=0.35, p<.001). (p13,
para.4).
The mean number of
questions patients
asked per consultation
was 3.9 (SD 3.6). (p13,
para.5).
The majority of patients
did attempt to selfdiagnose (n=68).
However only 8 patients
requested a specific
treatment and only 3
proposed an alternative
treatment to the one
offered by the dentist. In
about half of the
consultations the
patient decided to
undergo the
recommended
treatment (n=42),
among the other half
the decision was made
by the dentist (n=45). 2
patients handed handed
the decision over to the
dentist and in one case
no decision was made
at the time. (p13,
para.6).
Because of the low
number of patients who
334
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
for good. (p12, para.8).
Time points
measured: At the end
of the consultation.
(p12, para.3).
Outcome name:
Relationship between
communicative
behaviour and
satisfaction (p14,
para.1).
Outcome definition:
Relationship between
communicative
behaviour and
satisfaction (p14,
para.1).
Outcome measure:
Questionnaire and
observations from the
consultation (p14,
para.1).
Outcome measure
validated: NR
Unit of measurement:
Questionnaire
responses and
observations made
during the
consultations.
Time points
measured: At the end
Results
Notes by review team
requested a specific
treatment or proposed
alternative treatment
options no additional
analyses could be
made. (p13, para.6).
Intervention group(s):
Relationship between
communicative
behaviour and
satisfaction
Baseline: N/A
Follow up (all time
points): N/A
End point: Patients
who asked more
questions during their
visit to the dentist were
slightly, though not
significantly, more
satisfied with the
communicative
behaviour of the dentist
than patients who
asked less questions
(t=1.8, p=.07). No
difference in satisfaction
was observed in
relation to the types of
questions asked. No
difference in dentist
satisfaction was
observed either related
to how many questions
were asked by the
335
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
of the consultation.
(p12, para.3).
Method of analysis
(indicate if ITT or
completer analysis was
used and if adjustments
were made for any
baseline differences in
important confounders):
In order to investigate
whether patients’ and
dentists’ satisfaction
was related to patients’
and dentists’
communicative
behaviour correlation
coefficients were
calculated and linear
regression analyses
were performed. T-tests
were also performed.
(p.12-13)
Results
Notes by review team
patient. (p14, para. 1).
Whether patients did or
did not attempt to selfdiagnose made no
difference to their
satisfaction with their
own or the dentists’
communicative
behaviour. However
dentists’ satisfaction
with their own and
patients’ communicative
behaviour was higher
when interacting with
patients who did
attempt to selfdiagnose, compared to
those who did not
(t=2.1, p=.04; t=2.7,
p=.01 respectively).
(p14, para.2).
Patients who made the
decisions about the
treatments themselves
were significantly more
satisfied with their
communicative
behaviour than patients
who did not decide
themselves (t=3.6,
p<.001). The
satisfaction of the
dentist was not
influence by whether or
336
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
not patients made the
decision themselves.
(p14, para.3).
Patients’ satisfaction
with their own and
dentists communicative
behaviour was
positively related to the
dentists’ communicative
behaviour (r=0.32,
p<.002; r=0.34, p<.001
respectively). (p14,
para.4).
To determine the
relative influence of
dentists’ and patients’
behaviour 4 linear
regression analyses
were performed, with
the following 4
dependent variables:
patients’ satisfaction
with their own
communicative
behaviour, patients’
satisfaction with the
communicative
behaviour of the dentist,
dentists’ satisfaction
with patients’
communicative
behaviour, and dentists’
satisfaction with their
own communicative
337
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
behaviour. (p14,
para.5).
(Table 3 p.14) The
variance in patients’
satisfaction with both
their own and the
dentists’ communicative
behaviour was mainly
explained by dentists’
communicative
2
behaviour (R =0.19,
p<.05). None of the
variables studied
explained any variance
in dentists’ satisfaction,
except for the variable
‘self-diagnosis’ but then
only a small amount
(dentist satisfaction with
own behaviour:
2
R =0.05, p=.032; dentist
satisfaction with
patients’ behaviour:
2
R =0.08, p=.006). (p14,
para.5).
Attrition details:
Indicate the number lost
to follow up and
whether the proportion
lost to follow-up differed
by group (i.e.
intervention vs control)
10 out of the 119
patients approached
338
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
declined to participation
within the study. 6
patients initially agreed
but failed to complete
the post-appointment
questionnaire. 13
recordings were
unusable due to their
lack of quality. (p.12,
para.2).
Conclusion: The
results show that the
patients as well as
dentists are very
satisfied with dental
emergency
consultations. (p.14,
para.6).
High patient satisfaction
in particular among
older patients is
consistent with findings
from other studies.
(p.14, para.6).
However patients in this
study did not engage in
a lot of informationseeking behaviour.
Besides most patients
did not ask the dentist
for a specific treatment,
nor did they propose
alternative treatment
339
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
options to the one
offered by the dentist.
(p.14, para.6).
Active patients were not
more satisfied with their
communicative
behaviour nor were less
satisfied with the
dentists’ communicative
behaviour than passive
patients. Although
patients who made the
decision about the
treatment themselves
were more satisfied with
their communicative
behaviour than patients
who let the dentist
decide. (p.14, para.7).
Results from a
regression analysis
showed that patients’
satisfaction with
emergency
consultations is
determined by the
greater part by the
communicative
behaviour of dentists.
However scores on the
CDSS showed that
dentists’ communicative
behaviour towards
dental emergency
340
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
patients’ is rather
neutral. (p14-15
para.8).
341
Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: A. G.
Threlfall, C. M.
Hunt, K. M.
Milsom, M. Tickle
and A. S. Blinkhorn
Study design: Qualitative
study using semi-structured
interviews (abstract)
Population the sample was
recruited from: GDPs
practising in Lancashire,
Cheshire and Greater
Manchester. (Paper One:
p.1 para.3)
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Limitations identified by
author: NR
Year: 2007
Citation:
Paper One:
Threlfall, A.G., et
al., Exploring the
content of the
advice provided by
general dental
practitioners to
help prevent caries
in young children.
British Dental
Journal, 2007.
202(3): p. E9;
discussion 148-9.
(Content)
Paper Two:
Threlfall, A.G., et
al., Exploring
factors that
influence general
dental practitioners
when providing
advice to help
prevent caries in
children. British
Dental Journal,
2007. 202(4): p.
E10; discussion
Research aims, objectives,
and questions: To increase
understanding about the care
GDPs provide for young
children and explore the
nature of the advice and
preventive care they offer
(Paper One: p.1 para.2)
To increase understanding
about how to and to whom
GDPs provide preventive
advice to reduce caries in
young children (Paper Two,
p.1, para.1).
Theoretical approach
[grounded theory, IPA etc]:
Analysis of the content was
undertaken using a grounded
theory approach to identify
the key concepts that
emerged (Paper One) and to
identify factors that might
influence the provision of
preventive advice (Paper
Two). A grounded theory
approach is a qualitative
research method that uses a
systematic approach in order
to inductively derive theory
about a phenomenon. The
theory derived is both
How sample was
recruited: The study
population was drawn from
GDPs practising in
Lancashire, Cheshire, and
Greater Manchester in 2003.
Dentists were selected at
random from the General
Dental Council’s register and
sent a letter inviting them to
participate. This process
continued until
approximately 100 GDPs
had agreed to participate.
The dentists were selected
at random to avoid any bias
associated with a
convenience sample and all
the dentists who replied and
wanted to participate were
entered into the study. The
sample size was not
determined by statistical
considerations but aimed to
be sufficiently large and
varied to capture the full
range of views and opinions
of GDPs working within the
region. (p.1 para.3)
Paper One:
In brief, the transcripts were analysed
without pre-conceptions about the
expected content and themes emerged
by using a constant comparative
method [this follows the grounded
theory approach described under the
Research Parameters column].
Analysis continued until saturation of
concepts was reached, that being when
no new concepts can be identified.
Here findings relating to the GDPs’
views about prevention and the content
of the advice provided are presented.
The qualitative analysis was undertaken
by CH and AT who are health service
researchers and are not dentists. (p.2
para 2)
Paper Two:
In this study the data from the 93
transcribed GDP interviews were
analysed using a grounded theory
approach to identify factors that might
influence the provision of preventive
advice. The constant comparison
technique was used to analyse the
transcripts. The method used involved
initially coding data and constantly
comparing new data, firstly with new
incidents in the data and then with
Limitations identified by
review team:
The qualitative approach did
provide considerable depth
which may not have been
captured in a quantitativeonly study. However, given
the size of the sample, it
would have been useful to
have included some
quantitative questions and
analysis. For example - it
would have been useful if
the number of dentists
proscribing fluoride
supplements or advising
against fizzy drinks was
reported.
Information was not
provided on how data was
stored and record keeping
made systematic.
No information is provided
on how the research was
presented to the participants
and the relationship between
the participants and the
researchers does not appear
to have been considered.
Information on participant
342
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Study Details
Researh Parameters
216-7.
(Different
senders)
generated from the data
collected and also
provisionally tested by that
data. The purpose is to build
a theory that is faithful to the
data collected and illuminates
the area under study (p.2
para.2).
Country of study:
England
Quality Score (++,
+, or -) +
State how data were
collected:
What method(s): Each
participant was interviewed
separately. During the
interviews each dentist was
encouraged to speak freely
about the care they provide to
the primary dentition. The
interviews were semistructured around a set of
themes that were agreed
following group work with a
panel of experienced GDPs
and specialists in paediatric
dentistry. One of these
themes was prevention of
caries in the primary dentition.
All interviews were tape
recorded, numbered for
anonymity, and transcribed
verbatim. (Paper One: p.2
para.1)
By whom: One of 3 trained
interviewers who were not
dentists. (Paper One: p.2
para.1)
What setting: The dentists’
Population and Sample
Selection
How many participants
recruited: 311 invited to
participate. 96 initially
agreed. 2 withdrew from the
study due to time constraints
in practice and one because
of illness. Therefore 93
dentists were interviewed
(p.2 para 3)
Sample characteristics:
Age: NR
Sex: Males=70; Female= 23
(p.2 para 3)
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: NR
Occupation: NR
Education: NR
Socioeconomic position:
NR
Social capital: NR
Outcomes and Methods of Analysis
Notes by Review Team
codes and categories. This was
continued until very few or no new
categories were emerging from the
transcripts. Data analysis was iterative,
new emerging codes were used to
examine existing codes in more depth.
The concepts and categories that
emerged from the data were formed
into themes, which were the key factors
that emerged from the transcripts as
influencing the provision of preventive
advice. The themes were considered
together and discussed in an attempt to
identify theory that might connect them.
characteristics is limited. It
would have been useful to
have more socio-economic
context on the areas the
dentists operate in and to
see whether there are any
differences in advice
provided.
Key themes and findings relevant to
this review [with illustrative quotes if
available]
Paper One:
No triangulation appears to
have taken place and only
one method was used.
However given the findings
presented are quite general
and 3 different researcher
conducted interviews it is
unlikely that there will be
major issues with reliability.
Most dentists believed that diet was the
most important factor when providing
preventive advice to children.(p.2
para.5)
Given the size of the sample
the paper would have
benefited from some
discussion of differences
between dentists in different
areas serving different
communities. Also it would
be useful if some figures
were provided for some of
the responses - again it
seems peculiar that they
aren't given that the study
had such a large sample for
a qualitative piece of work.
‘Although tooth brushing is important, in
the first years of life I would stress that
diet control is more important. I’m not
While 2 researchers were
involved in the analysis it is
not clear how differences
[Paper One: Note on paragraph
references: New text is only treated
as in a separate paragraph to
previous text where there is a space
between them]
Inclusion criteria: NR
Diet v brushing
Exclusion criteria: NR
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Researh Parameters
homes or places of work.
(Paper One: p.2 para.1)
When: Conducted between
March 2003 and September
2003. (Paper One: p.2
para.1)
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
saying don’t brush the teeth but control
the sugar in the diet more so than being
over zealous about tooth brushing.’
(1000, male dentist, 19 years
experience.) (p.2 para.6)
between them were
resolved.
However some dentists focussed
strongly on regular toothbrushing rather
than diet, believing it was more realistic
to change brushing than eating
behaviour. (p.2 para.8)
Content of dietary advice
In general, the diet advice provided was
about reducing the intake of sugary
foods and drinks, with many stressing
that frequency of sugar consumption
was the most important message to get
across. (p.2 para.10)
Some dentists believed in providing diet
advice that they thought realistic and
suggested approaches to reduce the
frequency and regulate the periods of
sugar consumption. These included
replacing sweets with savoury
alternatives, fizzy drinks with milk,
flavoured water, or weak diluted fruit
juices and eating sweets at mealtimes
or in one sitting. (p.2 para.12)
‘Stop sugary drinks before you go to
bed at night. I recognised that the child
wasn’t going to stop eating sugar and I
said if you could limit it to ideally once a
The findings are clearly laid
out and a sufficient number
of extracts are provided to
illuminate them. However as
mentioned it would have
been useful if some
response numbers had been
provided as opposed to just
relying on terms such as
"most" and "some".
The focus is very much on
the content of the message
and not how the message is
delivered.
The conclusions clearly
enhance the understanding
of this research area.
However the conclusion
does not clearly set out the
limitations of the study. Also
the authors claim that they
have "no reasons to believe"
that the findings may not
apply to other areas of the
UK, whereas it would have
been better to suggest
additional research to
explore if there are any
regional differences (which
could for example result
from the practices of
different health authorities).
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Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
week and eat all the sweets in one
go…’ (1013, male dentist, 6 years
experience.) (p.2 para.14)
Ethical issues are not
mentioned
Drinks emerged as a key part of many
dentists advice on prevents. For many
dentists the dangers of fizzy drinks
were singled out. (p.2 para.15)
Advice on reducing fizzy drinks
Reasons given for not drinking fizzy
drinks varied; some stressed the
importance of acid erosion whilst others
stressed the risk of decay from high
sugar content. (p.3 para.1)
Advice on extrinsic sugars
This was another source of variation.
Some dentists were especially
concerned about sugars in savoury
foodstuffs and foodstuffs commonly
considered as healthy, like yoghurt, but
most did not mention hidden sugars.
(p.3 para.3)
Fluoride supplements
Approximately half of the dentists
indicated that they currently prescribe
fluoride supplements to their child
patients. Some dentists prescribing
fluoride supplements did so to most of
their child patients whilst others only
prescribed to specific patients, for
example those who had not responded
to dietary and oral hygiene advice. (p.3
para.5)
Evidence gaps and/or
recommendations for
future research: There is a
need to develop and test a
widely accepted, evidencedbased dental health advice
and fluoride use programme
with clear and concise
messages that primary care
dentists can deliver in
practice. Such a
development would
discourage a piecemeal,
subjective approach to
prevention and instead
ensure the delivery of an
appropriate set of messages
that could be delivered in a
consistent and qualityassured manner. The
development of Clinical Care
Pathways within the new
dental contract offer an
opportunity to introduce an
evidenced-based priority list
of specific preventive
messages that can be
adopted by NHS dentists.
(Paper One: p.4 para.3)
The arrival of the new dental
contract provides an
opportunity for change by
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Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Reasons for not proscribing fluoride
included fear of fluorosis and some had
stopped because of this as well as
difficulties with compliance. (p.3 para.8)
placing prevention at the
heart of dental care and
allowing dentists to spend
more time with children. This
opportunity will be lost
unless efforts are made to
both improve the content
and delivery of preventive
advice and to uncover
simple interventions that
might result in improving
usage of fluoride toothpaste
and changing children’s
diets. These interventions
will need to be developed in
partnership with patients if
the prescriptive mindset of
GDPs towards prevention is
to be challenged. Research
can be undertaken to test
innovative approaches and
identify better ways of
delivering preventive care.
Training can be provided,
both as part of the
undergraduate curriculum
and as part of continuing
professional development, to
improve the delivery of
preventive care by
promoting a better
understanding about
counselling skills and
educative techniques. In
addition, individual GDPs
need to reflect on their own
delivery of preventive care to
‘We used to have a policy of giving
fluoride supplements but I
was scared that people would get
fluorosis and such things so we went off
it. I never saw any. Rumours.’ (118,
male dentist, 14 years experience.) (p.3
para.9)
NOTE: Dentists also discussed water
fluoridation in the interview but this did
not concern oral health messages as
such so these findings have not been
included.
Conclusions:
The dentists in this study were aware of
the basic principles of preventive
dentistry, but their care and advice
varied in content and emphasis. The
majority felt that diet control should be
the cornerstone of their preventive
advice, but others were more
concerned to stimulate regular tooth
brushing habits. Only half of the
dentists reported prescribing fluoride
supplement. (p.3 para.15)
The focus of most dietary advice was
the consumption of sugar. The
consumption of fizzy drinks was singled
out as very important by some but not
all dentists, and advice about these
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
drinks also varied. (p.3 paras 16-17)
identify ways in which it
might be improved. (Paper
Two: p.4, para.4)
A surprising finding was the degree of
variation amongst the GDPs in their
attitude towards fluoride and their use
of fluoride supplements. Whilst some
use these supplements widely, others
adopt a targeted approach, yet others
prescribed them on demand and some
did not prescribe them because they
are frightened of the possible side
effects. (p.3 para.18)
Source of funding: NR
The findings demonstrate that these
GDPs do not deliver caries preventive
messages in a similar and consistent
manner. Whilst there is an acceptance
amongst them that the key messages of
oral hygiene and sugar control need to
form the basis of practice-based caries
prevention, there is no unified approach
to the emphasis that should be placed
on the practical delivery of information
to children and their carers. If the
findings from this large group of GDPs
are transferable to GDPs practising in
other regions of the UK, and we have
no reasons to believe otherwise, then
UK dentists are selectively delivering a
range of preventive messages and care
based in part on their own experiences
and possible prejudices. Perhaps the
inconsistency of approach toward
caries prevention in young children
among GDPs, especially in their use of
fluoride, offers a partial explanation for
the lack of recent progress in reducing
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
caries in the primary dentition of UK
children. (p.4 para.2).
Key themes and findings relevant to
this review [with illustrative quotes if
available]
Paper Two:
(p.2-3)
Patient factors:
- Gender or ethnicity was not
important to GDPs when giving
advice
- Age influenced the delivery of
advice but not the likelihood of
providing advice.
- Attitude and behaviour of a child
was important for making treatment
decisions but not a major factor
when providing advice.
- The amount of caries the child had
was crucial to treatment decisions
and the advice provided.
- Children with caries were
questioned about diet and oral
hygiene behaviour but those
without tended not to be
questioned.
“If I see a child and oral hygiene is
good, I would say very little about
what they are doing because
whatever they are doing they are
doing alright”
- Children presenting with caries on
more than one occasion were either
given similar message again or
given fluoride tablets or fluoride
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
-
Notes by Review Team
varnish.
In some cases if dentists felt advice
was not observed they became
unmotivated about providing
advice:
‘If I give tablets it’s usually for a
patient who keeps coming back and
back, and you are getting nowhere
with the diet advice and the oral
hygiene advice…then I am more
likely to give fluoride tablets at that
stage. But I wouldn’t do initially.’
Parent factors:
- The GDPs’ perception of the
accompanying parent, especially
their beliefs about parental attitude
and motivation, were crucial to the
provision of preventive advice: in
general if dentists believed parents
were well motivated they gave
more advice.
- A link between social class and
parental motivation was also
mentioned:
- “Some mothers, particularly middle
class will come in and talk at great
length about fluoride…”
- The dentist’s belief that the advice
they provided was acted upon by
some parents was an important
factor in ensuring that they
continued to provide advice.
- Dentists reported that many parents
were ignorant about the causes of
tooth decay and they often tried to
make sure that parents understood
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Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
the causes of decay and the
harmful effects of sugar.
External factors:
- Practices with a hygienist tended to
have an increased emphasis on
dietary advice and oral hygiene
instruction:
“All children to see a hygienist on a
regular basis…because they do the
best prevention care”
- Many respondents referred to the
problem of time restrictions and
many linked this problem to the fee
structure.
- An overarching theory emerged
from the transcripts; GDPs see
themselves in the role of health
educators when considering
prevention.
- There was an almost universal
belief that caries could be
prevented if parents listened to and
understood the diet advice and oral
hygiene instruction provided.
- The majority of dentists relied on
verbal advice in the form of a short
educative talk and some also
handed out leaflets.
- Although dentists saw themselves
as health educators, there was little
evidence that they used techniques
such as visual aids to increase the
impact of their preventive advice.
Conclusions
(p.4)
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Study Details
Researh Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Preventive advice provided in the dental
practice is given in an ad hoc way with
no formal targeting of patients. Most
GDPs tend to deliver preventive advice
in a similar manner, a short educative
talk with no props or additional
materials. In addition, there was no
planned reinforcement of advice.
Greater use of visual aids, providing
materials for parents to take home, and
greater emphasis on partnership might
help improve the impact of GDPs’
advice.
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author:
Vachirarojpisan, T,
Shinda, K,
Kawaguchi, Y
Source
Population(s):
Country of study
(include if developed
or non-developed)
NR
Method of allocation (describe
how selected individuals/clusters
were allocated to intervention or
control groups – state if not
reported): randomised by health
centres
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
For each outcome
report
Limitations identified
by author:
Means, SDs, pvalues, CIs, Effect
sizes, SEs
Setting: Health
centres in the rural
district of Suphanburi
Province, Thailand
Report how confounding
factors were minimised: There
were no significant differences at
baseline. Contamination was
minimised as separate clinics
were used for the control and
intervention groups.
Outcome name:
Healthcare centre staff
impact evaluation
Outcome definition:
Questionnaire survey
to evaluate the
programme’s impact on
health centre staff and
whether they had a
better knowledge and
attitude toward the
ECC problem
Outcome measure:
Questionnaire
Outcome measure
validated: Unclear
Oral health (clinical)
results:
The ECC problem in
Thailand remains a
critical and sever
problem, therefore this
single intervention in
the short term is not
seen as sufficient to
prevent the
development of ECC
Year: 2005
Citation:
Vachirarojpisan, T.,
Shinada, K., and Y.
Kawaguchi. The
process and
outcome of a
programme for
preventing early
childhood caries in
Thailand.
Community Dental
Health (2005). 22,
253-259
Country of study:
Thailand
Aim of Study: the
aim of this
preliminary study
was to evaluate the
process of the
participatory-DHE
programme and the
effectiveness of this
intervention on
reported changes in
Location (urban or
rural): Rural
Sample
characteristics:
Age: Children: 6 – 19
months
Children’s average
age: Intervention=
12.09 (presumably
months?); Control=
12.24
Mothers/ caregivers
average age:
Intervention= 30.28
(presumably years);
Control= 29.70
Sex: Intervention
group: Male= 120
(56.3%); Female= 93
943.7%); Control
group: Male= 96
Programme/Intervention
description:
What was delivered:
Small group discussion with 6-8
mothers/caregivers on their
children’s oral health and
causes and prevention of ECC
three times, at 3 monthly
intervals, change from didactic
formal lecture approach to
opportunity to choose the ECC
preventive methods they
believed suitable for their
children.
The series of discussion topics
depended on the points of
interest that arose within each
group. The discussion groups
Unit of measurement:
Questionnaire
response
Time points
measured: New
Outcome name:
Effects of
mothers/caregivers
Children’s dental
cavitated carious
increment:
Mean scores (with
standard deviations in
brackets)
Health centre staff had
a different experience
and ability to moderate
group discussions
Non-cavitated carious
lesions:
Intervention:
Baseline:1.38 (2.12)
1 year follow-up: 3.98
(3.08)
Some
mothers/caregivers did
not attend all three
sessions and sent a
representative to join
the discussion
Control:
Baseline: 1.47 (2.14)
1 year follow-up: 4.04
(2.99)
Potential of crosscontamination of
results between
subjects who lived in
the adjacent
household but did not
attend the same health
centre.
Cavitated carious
lesions:
Intervention:
Baseline: 0.36 (1.06)
1 year follow-up: 3.82
352
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
the oral health
behaviour of
children and the
impact outcome on
cavitated carious
increment over a
one-year period.
(50.3%); Female= 95
(49.7%)
Sexual orientation:
NR
Disability: NR
Ethnicity: Thai
Religion: NR
Place of residence:
Rural Area
Occupation:
Mothers/ caregivers:
House wife (did not
work): Intervention
group= 130 (61.0%);
Control group= 100
952.4%)
Working:
Intervention= 83
(39.0%); Control= 91
(47.6%)
Education: Mothers/
caregivers: Primary
school or less:
Intervention group=
159 (74.6%); Control
group= 143 (74.9%)
Secondary school or
more: Intervention
group= 54 (25.4%);
Control group= 48
(25.1%)
Socioeconomic
position: Family
income per month:
Below Thai average:
took about 40-60 minutes.
Study Design:
One year
intervention
programme.
Subjects divided
into 2 groups by
randomising the
health centre they
attended. Small
group discussion
with active
involvement was
provided in the
intervention group
while the routine
national teaching
DHE programme
was provided in the
control group.
Children’s caries
status and oral
health behaviour
evaluated and
compared between
the 2 groups at the
end of the study.
“Observational
Free toothbrushes and fluoride
toothpaste were distributed to
mothers/caregivers after each
session
Theoretical basis: NR
By whom: Dentists and staff
from health centres
To whom: Participants
How delivered: Small group
discussions
When/where: health centres in
rural locations
How often: Baseline, 3 monthly
in Feb, May, Aug and Nov.
How long for: 12 month period
Control/Comparator
description:
What was delivered: Clinical
examination and questionnaire
interviews at baseline and one
year later.
Routine DHE prevention
programme: 10 health centres
provided DHE using the national
DHE programme. This
programme consisted of didactic
teaching about ECC prevention
methods and providing free
toothbrushes. This activity was
conducted at the same time as
the vaccination programme for
Outcome definitions
and method of
analysis
knowledge on ECC
Outcome definition:
Mothers/caregivers
knowledge of ECC
Outcome measure:
Questionnaire
Outcome measure
validated: Unclear
Unit of measurement:
Percentage of correct
answers
Time points
measured: End
Outcome name:
Childrens dental
cavitated carious
increment
Outcome definition:
Dental caries
measured to show the
presence of
noncavitated and
cavitated decayed
teeth using the portable
dental light with a
visual and non-tactile
technique (Kaste et al
1999). Examiners
attended 2 day
calibration exercise.
Outcome measure:
Dental caries
Results
Notes by review team
(3.65)
Control:
Baseline: 0.51 (1.38)
1 year follow-up: 3.74
(3.93)
ECC (non-cavitated
and cavitated carious
lesion):
Intervention:
Baseline: 1.73 (2.60)
1 year follow-up: 7.80
(4.99)
Control:
Baseline: 1.97 (2.76)
1 year follow-up: 7.78
(5.22)
Mean cavitated carious
increment:
Intervention: 3.46
(3.36)
Control: 7.78 (5.22)
There were no
statistical differences in
non-cavitated and
cavitated carious
lesions between both
groups at the baseline
and one year follow up
– Table 3 p.257
The children in both
Limitations identified
by review team:
The source population
is only partially
described.
The eligible population
or area population is
only partially
representative of the
source population or
area.
Participants were from
Thailand therefore
they do not fully
represent the eligible
population or area.
Allocation to the
intervention and
control groups was
done so via
randomisation by the
health centres.
Interventions and
comparisons were only
partially described.
Allocation to condition
was completed by
randomisation by
whole session.
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Study details
Population and
setting
Method of allocation to
intervention/control
method” used to
evaluate the
process of group
activities in the
intervention group.
Health centre staff’s
knowledge of ECC
problem evaluated
by questionnaire at
end of study.
Intervention= 115
(54.0%); Control=
107 (56.0%); Over
Thai average:
Intervention= 98
(46.0%); Control= 84
(44.0%)
Social capital: NR
children at the age of 9 and 18
months.
By whom: Dentists and staff
from health centres
To whom: Participants
How delivered: Didactic
teaching about ECC prevention
methods plus free toothbrushes.
When/where: health centres in
rural locations
How often: baseline, then at 9
and 18 months old.
How long for: 12 month period
Quality Score (++,
+, or -):
+
External
Validity(++, +, or ):
+
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): Voluntary
entry to the study
State if eligible
population is
considered by the
study authors as
representative of
the source
population:
+
Inclusion Criteria:
Mothers/caregivers of
Children born
between March 2000
and April 2001 aged
6-19 months old
Exclusion Criteria:
NR
Sample size at baseline: NR
Total sample N = 520
Intervention group N = 270
Control Group N = 250
Baseline comparisons (report
any baseline differences
between groups in important
confounders): There were no
statistically significant
differences in any characteristics
of mothers/caregivers and
children who belonged to the
intervention and control groups
at the outset.
Study sufficiently powered
(power calculations and provide
details): NR
Outcome definitions
and method of
analysis
Outcome measure
validated: Unclear
Unit of measurement:
Kappa Score
Time points
measured: Beginning
and End
Outcome name:
Stated changes in Oral
health behaviour
Outcome definition:
The percentages of
children according to
oral health behaviour
Outcome measure:
percentage of children
according to oral health
behaviour
Outcome measure
validated: Unclear
Unit of measurement:
Percentage
Time points
measured: Beginning
and End
Method of analysis
(indicate if ITT or
completer analysis was
used and if
adjustments were
Results
intervention and control
groups had the same
order of magnitude of
increase in cavitated
carious lesions during
the one year period
(Table 4 p.257). The
proportion of children
with cavitated carious
increment was 74.2%
and 68.1% in the
intervention and control
groups, respectively.
Behavioural results:
Healthcare centre
staff impact
evaluation
About half of health
centre staff reported a
difficulty in finding
appointment times for
the groups and how to
lead and moderate the
groups.
16 of 17 of health
centre staff stated that
they would like to
extend the topics of
discussion for their
clients in this small
group format, to other
Notes by review team
It was not recorded
whether the exposure
to the intervention or
control group was
adequate.
In the intervention
group they also
received free fluoride
toothpaste alongside
the free toothbrush.
The intervention was
conducted in Thailand
and is therefore does
not fully reflect the
usual UK practice. It
was also a
participatory
programme so again it
does not fully reflect
usual UK practice.
It was not recorded
whether the outcome
measures were
reliable.
The outcome
measures were not
included within the
research.
Some of follow up
times were not the
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
% of selected
individuals agreed
to participate: 57
subjects (21.1%)
(Intervention group),
59 subjects (23.6%)
(Control group)
dropped out mainly
due to
mothers/caregivers
moving out of the
area or refused to
continue in the
programme.
Potential sources of
bias: NR
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
made for any baseline
differences in important
confounders): ChiSquare was used to
compare results for
individual components
of oral health
behaviour. The T-Test
was used to compare
results for dental
cavitated carious
increment.
Results
Notes by review team
areas of general health
of children.
same in each
condition.
Effects of
mothers/caregivers
knowledge on ECC
ITT was not recorded.
Almost 100% of
mothers/caregivers in
both groups were able
to identify that “candy”
and “no brushing
behaviour” were the
causes of ECC.
Stated changes in Oral
health behaviour
In the intervention
group the proportions
of the children brushing
their teeth using
fluoride toothpaste and
using a proper amount
of toothpaste were
higher at one-year
follow up than in the
control group
(p<0.001). Other oral
health behaviours such
as consumptions of
sweet food between
meals, night time
bottle-feeding and
falling asleep with a
bottle also showed
Power was not
recorded and neither
were the estimates of
effect size.
It was not reported
whether the analytical
methods were
appropriate.
Some p values were
given when
considering the
precision of the
intervention effects
that were given.
The data from this
study has only partial
internal validity.
The data from this
study has only partial
external validity.
Evidence gaps: NR
Source of funding:
NR
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
similar results in both
groups.
Oral health
behaviour:
ns= not significant
Any tooth brushing:
Intervention:
Baseline: 18.3%
1 year: 93.0%
Control:
Baseline: 17.3%
1 year: 73.8%
Result of chi-square:
Baseline: ns
1 year: 0.001
Parent brush their child
teeth:
Baseline: 13.6%
1 year: 76.0%
Control:
Baseline: 15.2%
1 year: 59.7%
Result of chi-square:
Baseline: ns
1 year: 0.001
Brushing twice a day:
Baseline: NR
356
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
1 year: 41.8%
Control:
Baseline: NR
1 year: 26.7%
Result of chi-square:
Baseline: NR
1 year: 0.001
Fluoride toothpaste
use:
Baseline: 8.9%
1 year: 97.3%
Control:
Baseline: 7.3%
1 year: 58.1%
Result of chi-square:
Baseline: ns
1 year: 0.001
Proper amount of
toothpaste:
Baseline: NR
1 year: 73.2%
Control:
Baseline: NR
1 year: 38.2%
Result of chi-square:
Baseline: NR
1 year: 0.001
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Falling asleep with
bottle:
Baseline: 34.3%
1 year: 27.7%
Control:
Baseline: 37.2%
1 year: 24.1%
Result of chi-square:
Baseline: ns
1 year: ns
Night time feeding:
Baseline: 43.7%
1 year: 40.4%
Control:
Baseline: 44.0%
1 year: 35.1%
Result of chi-square:
Baseline: ns
1 year: ns
Sweet food dietary
between meal:
Baseline: 88.3%
1 year: 91.5%
Control:
Baseline: 92.1%
1 year: 90.6%
Result of chi-square:
Baseline: ns
358
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
1 year: ns
Attrition details:
Indicate the number
lost to follow up and
whether the proportion
lost to follow-up
differed by group (i.e.
intervention vs control)
57 subjects (21.1%)
(Intervention group), 59
subjects (23.6%)
(Control group)
dropped out mainly
due to
mothers/caregivers
moving out of the area
or refused to continue
in the programme.
Conclusion: Results
revealed the
effectiveness of a
participatory DHE
approach to increase
tooth brushing and
fluoride toothpaste
behaviour as preferred
individual/collective
choices for preventing
ECC.
359
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author: Wang, S.J
et al
Source
Population(s):
Parents of 4 to 10
year old paediatric
dental patients (at
Pediatric Dental
clinic at Mott
Children’s Health
Center, Flint,
Michigan, USA)
who needed
operative
treatments.
Method of allocation (describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported):
The parents were randomly
assigned with a random number
table to 1 of 4 conditions for the
treatment plan consultation.
Outcomes (include
details of all relevant
outcome measures
and whether measures
are objective or
subjective or otherwise
validated):
Oral health (clinical)
results:
Limitations identified by
author:
NR
Year: 2010
Citation: Wang,
S.J., Briskie, D., Hu,
J.C.C., Majewski, R.,
Inglehart, M.R., and
P. Habil. Illustrated
information for
Parent Education:
Parent and Patient
Responses.
Pediatric Dentistry.
2010; 32:295-303
Country of study:
USA
Aim of Study: The
purpose of this study
was to explore the
effect of using
illustrations, when
educating parents
about their child’s
upcoming operative
appointment, on
parents’ and child
patients’ responses
to the treatment. The
studies objectives
were to analyse
Setting: Pediatric
Dental clinic at
Mott Children’s
Health Center,
Flint, Michigan,
USA
Location (urban
or rural): NR
Sample
characteristics:
Age: Children were
between 4 and 10
years. Average age
= 6.7 years old.
Adults: 164
mothers, 18
fathers, 1
grandfather, 2
foster parents, 1
Report how confounding
factors were minimised:
Analysis was undertaken to
compare baseline participants in
all intervention/control groups
(including demographic
background, own oral healthrelated characteristics,
perceptions of their child’s oral
health and oral health-related
behaviour, and knowledge and
attitudes concerning the
importance of their child’s
primary dentition and other oralhealth-related issues) - no
significant differences found
Programme/Intervention
description:
Intervention Group 1 –
standardised information (flip
chart):
What was delivered:
Outcome name:
Returning for operative
appointment either
right away or after
rescheduling (Goal 1 –
whether the use of
illustrative educational
aides improved the
parent’s/guardians
responses to the
operative
appointment)
Outcome definition:
Whether the use of
illustrative education
aides improved
parents/guardians
responses to the
operative appointment
compared to the
responses of the
parents’/guardians’
who were only given
verbal instructions
Outcome measure:
percentages of
patients who returned
Plaque scores
Mean:
Intervention groups
(combined result of
group 1, 2 and 3):
End point: 1.01
Control group:
End point: 1.21
p value: p<.06
Gingival health
Mean:
Intervention groups
(combined result of
group 1, 2 and 3):
End point: 1.71
Control group:
End point: 1.87
Limitations identified by
review team:
No information on whether
allocation into groups was
concealed or whether
participants/investigators
were blind to exposure
and comparison.
The study isn’t a UK
setting: participants are
Medicaid-eligible children.
For some
outcomes/results the 3
intervention groups were
reported on as one group
– therefore the distinction
between the impacts of
each group/intervention is
not clear.
Behavioural results:
Exact follow up times are
not clear (although each
follow-up is less than 11
weeks)
Returning for
operative
appointment either
right away or after
Evidence gaps:
This study showed that the
way this information was
provided, namely with the
p value: p<.22
360
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
whether informing
parents/guardians
about their child’s
oral healthcare
needs with a
standardised
illustrated
educational tool, an
individualised
illustrated drawing,
or both illustrated
educational tools
would result in a
better response from
the parent and the
child compared to
responses when
verbal
communication
strategies were
used.
adult sibling.
Average age =
31.52 years old.
Sex: Children = 88
males, 101 females
Sexual
orientation: NR
Disability: NR
Ethnicity: Children
= 95 African
Americans/52
European
Americans/6 Asian
Americans/ 5
Hispanics/ 21
biracial
Religion: NR
Place of
residence: NR
Occupation: NR
Education: NR
Socioeconomic
position: Families
must have an
annual income of
not greater than
200% of the federal
poverty level
Social capital: NR
Initial hygiene/treatment plan
appointment: Parents undertook
a baseline survey: including
questionnaires on perceptions of
their own oral health, their
children’s oral health, and their
dental fear; knowledge about
oral health and their
understanding of operative
treatment; perception of the
importance of the primary
dentition; and satisfaction with
the previous communication
about their children’s dental
treatment needs.
Parents were informed with the
help of a standardised illustrated
education tool (flip chart) and
given verbal information.
The flip chart had 3 separate
pages with drawings of the
primary definition showing the
progression of dental caries
from healthy teeth to pulpal
involvement. To standardise the
instruction, a prewritten script
about dental caries progression
of the primary teeth was read to
the parents, regardless of each
patient’s treatment needs, when
showing the flip chart
information.
Following operative
appointment: Following the
operative appointment, the
Study Design:
Parallel RCT. If the
child required an
operative visit, the
parents were
randomly assigned
with a random
number table to 1 of
4 conditions for the
treatment plan
consultation.
Quality Score (++,
+, or -): +
Eligible
population
(describe how
individuals,
groups, or
clusters were
Outcome definitions
and method of
analysis
for the operative
appointment either
right away or after
rescheduling
Outcome measure
validated: NR
Unit of
measurement: %
Time points
measured: Following
initial planning
appointment (the
intervention)
Outcome name:
Responses of the
parents/guardians at
the operative
appointment (Goal 1 –
whether the use of
illustrative educational
aides improved the
parent’s/guardians
responses to the
operative appointment:
Effect of information at
the planning
appointment)
Outcome definition:
Whether the use of
illustrative educational
aides improved the
parent’s/guardians
responses to the
operative appointment:
responses of the
Results
Notes by review team
rescheduling
Percentage:
help of illustrations, was a
crucial determinant of the
parents’ – and even child’s
– responses following the
operative appointment. It
could be that the visual
information given allowed
the parents to visualise
their own children’s
disease status, resulting in
a sense of increased selfefficacy and trust of the
dental provider. It might be
beneficial to explore and
define the underlying
process that motivated the
parents and patients and
mediated those positive
outcomes. Future
research should explore
these underlying
processes to pinpoint
patient and parent
motivation.
End point:
Intervention group
1: 87%
Intervention group
2: 84%
Intervention group
3: 94%
Control: 71%
P=.02
An analysis of
average days
between the
treatment plan
consultations and the
operative
appointments showed
that an average
number of days in the
4 conditions did not
differ significantly
(control =35.38 days,
vs. standardised
condition = 34.17
days, vs.
individualised
condition = 38.73
days, vs. combined
condition = 47.08
day, p=.06)
Source of funding:
The research was
supported by a grant from
the Delta Dental
foundation of Michigan.
Responses of the
parents/guardians at
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
External
Validity(++, +, or -):
+
Population and
setting
Method of allocation to
intervention/control
recruited, e.g.
media
advertisement,
class list, area):
Parents whose
children met the
inclusion criteria
were identified at
the hygiene
appointment.
Parents were
invited to
participate in the
study, and if they
agreed, signed
consent and
HIPAA forms and
responded to a
baseline study.
parents and children responded
to a post-operative appointment
survey, which assessed their
responses to their child’s
treatment. Each dentist
assessed the child patient’s
behaviour with the Frankl
behaviour rating scale at 6
points during the appointment:
1. When seated in the dental
chair, 2. During administration of
local anesthesia, 3. During
rubber dam placement, 4.
During decay excavation or
tooth extraction, 5. During
restoration placement and 6.
Upon dismissing the patient.
The dentists also recorded
whether the parent was present
in the operatory and whether
nitrous oxide was used.
Gingival and plaque scores
taken.
Theoretical basis: N/A
By whom: Dentists
To whom: Parents (and child)
How delivered: Verbal
instruction and visual flip chart
When/where: Paediatric dental
clinic
How often: Pre-op visit
(planning appointment) followed
by operative visit How long for:
Operative appointment was less
than 11 weeks following initial
State if eligible
population is
considered by the
study authors as
representative of
the source
population:
NR
Inclusion Criteria:
Children between 4
and 10 years;
healthy; not
developmentally
delayed; free from
Outcome definitions
and method of
analysis
parents/guardians at
the operative
appointment
Outcome measure:
Questionnaire
Outcome measure
validated: NR
Unit of
measurement:
Various 5 point scales
(Q1: 1=not at all
helpful to 5=very
helpful; Q2: 1=I knew
nothing to 5=I knew
everything; Q3 and
Q6: 1=very nervous to
5=very relaxed; Q4:
1=very dissatisfied to
5=very satisfied; Q5:
1=very uncomfortable
to 5=very comfortable)
Time points
measured: At the
operative appointment
(less than 11 weeks
following initial
(intervention)
appointment)
Outcome name:
Plaque scores
Outcome definition:
Children’s oral hygiene
status.
Outcome measure:
Examination
Results
Notes by review team
the operative
appointment
Mean scores
How helpful was the
information we gave
you last time for
preparing your child
for his/her dental
treatment today? 1=
not at all helpful to
5=very helpful
End point:
Control: 3.74
Intervention group
1: 4.18
Intervention group
2: 4.11
Intervention group
3: 3.88
P value: .03
Before you came to
the appointment
today, how much did
you know about what
would be done? 1=I
knew nothing to 5=I
knew everything
End point:
Control: 3.56
Intervention group
1: 3.71
Intervention group
2: 3.98
Intervention group
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
other mental health
disorders. Children
were only included
if they did not
require
pharmacological
methods of
sedation other than
nitrous
oxide/oxygen in
order to perform
the operative
treatment.
hygiene and treatment planning
appointment. Whole study was
over 12 months
Children included
were seen for an
operative
appointment in less
than 11 weeks
following their initial
hygiene and
treatment planning
appointment
Exclusion
Criteria:
NR
% of selected
individuals
agreed to
participate:
99% (189 out of
191)
Potential sources
Programme/Intervention
description:
Intervention Group 2 Individualised illustration:
What was delivered: Parents
undertook a baseline survey:
including questionnaires on
perceptions of their own oral
health, their children’s oral
health, and their dental fear;
knowledge about oral health and
their understanding of operative
treatment; perception of the
importance of the primary
dentition; and satisfaction with
the previous communication
about their children’s dental
treatment needs.
Parents educated about their
child’s oral healthcare needs
and the upcoming operative
appointment verbally and
individualised illustration.
Parents were informed about
their children’s dental treatment
needs as they watched the
dental hygienist draw the child’s
treatment needs on a preprinted occlusal and crosssectional illustration of the
Outcome definitions
and method of
analysis
Outcome measure
validated: NR
Unit of
measurement: Scale:
0=no plaque to
3=heavy accumulation
of plaque
Time points
measured: At
operative appointment
Outcome name:
Gingival health
Outcome definition:
Children’s oral hygiene
status.
Outcome measure:
Examination
Outcome measure
validated: NR
Unit of
measurement: Scale:
1 = normal gingival to
4=severe inflammation
Time points
measured: At
operative appointment
Outcome name:
Children’s behaviour
during the
appointment
Outcome definition:
The dentist rated the
children’s behaviour
during the
Results
Notes by review team
3: 3.86
P value: .32
How nervous/relaxed
do you feel about
your child’s
appointment today?
1=very nervous to
5=very relaxed
End point:
Control: 3.90
Intervention group
1: 3.92
Intervention group
2: 4.11
Intervention group
3: 3.98
P value: .81
How satisfied are you
with what was done
today? 1=very
dissatisfied to 5=very
satisfied
End point:
Control: 4.41
Intervention group
1: 4.50
Intervention group
2: 4.66
Intervention group
3: 4.29
P value: .23
How comfortable
were you with what
363
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
of bias:
NR
primary dentition (as seen in a
bitewing radiograph of the
primary dentition and the first
permanent molars) using red felt
tip pen.
Following the operative
appointment, the parents
responded to a post-operative
appointment survey, which
assessed their responses to
their child’s treatment. Each
dentist assessed the child
patient’s behaviour with the
Frankl behaviour rating scale at
6 points during the appointment:
1. When seated in the dental
chair, 2. During administration of
local anesthesia, 3. During
rubber dam placement, 4.
During decay excavation or
tooth extraction, 5. During
restoration placement and 6.
Upon dismissing the patient.
Outcome definitions
and method of
analysis
appointment with the
Frankl behaviour
rating scale
Outcome measure:
Behaviour during
appointment
Outcome measure
validated: NR
Unit of
measurement: The
Frankl behaviour
scale: 1 = “definitely
negative”, 2 =
“negative”, 3 =
“positive”, 4 =
“definitely positive”.
Time points
measured: At
operative appointment
The dentists also recorded
whether the parent was present
in the operatory and whether
nitrous oxide was used.
Method of analysis
(indicate if ITT or
completer analysis
was used and if
adjustments were
made for any baseline
differences in
important
confounders):
ITT - NR
Gingival and plaque scores
taken.
Theoretical basis: N/A
By whom: Dentist
To whom: Parents (and child)
Analysis:
Chi-square tests were
used to analyse
whether the
percentages of
Results
Notes by review team
was done today?
1=very uncomfortable
to 5=very comfortable
End point:
Control: 4.25
Intervention group
1: 4.21
Intervention group
2: 4.47
Intervention group
3: 4.34
P value: .50
How nervous/relaxed
do you feel about
your child’s next
appointment? 1=very
nervous to 5=very
relaxed
End point:
Control: 4.24
Intervention group
1: 4.21
Intervention group
2: 4.29
Intervention group
3: 4.24
P value: .98
Child behaviour
during the operative
appointment
Mean score (n)
When seated in
dental chair
364
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
How delivered: Educated
verbally and with individualised
illustration
When/where: Paediatric dental
clinic
How often: Pre-op visit
(planning appointment) followed
by operative visit
How long for: Operative
appointment was less than 11
weeks following initial hygiene
and treatment planning
appointment. Whole study was
over 12 months
Programme/Intervention
description:
Intervention Group 3 Standardised and individualised
information (flip chart and
illustration):
What was delivered: Parents
undertook a baseline survey:
including questionnaires on
perceptions of their own oral
health, their children’s oral
health, and their dental fear;
knowledge about oral health and
their understanding of operative
treatment; perception of the
importance of the primary
dentition; and satisfaction with
the previous communication
about their children’s dental
treatment needs.
Outcome definitions
and method of
analysis
parents with different
educational
communications
differed in the
following 2 dependent
variables: 1) return for
operative appointment
and 2) staying in the
operatory with the
child during treatment.
Univariate analyses of
variances were used
to analyse whether the
parent sin the 4
conditions differed in
their responses to the
operative appointment.
Independent sample t
tests were used to
compare the
behaviour ratings of
children whose
parents had received
the traditional
information with the
ratings of children
whose parents had
received illustrative
information during the
health education
process. A
significance level of
P<.05 was used.
Results
Notes by review team
End point:
Control: 3.35 (77)
Intervention groups
(combined result of
group 1, 2 and 3):
3.62 (118)
P value: .03
During local
anaesthesia
administration
End point:
Control: 2.97 (36)
Intervention groups
(combined result of
group 1, 2 and 3):
3.39 (115)
P value: <.01
During placement of
the rubber dam
End point:
Control: 3.21 (33)
Intervention groups
(combined result of
group 1, 2 and 3):
3.36 (107)
P value: .31
During excavation of
the decay
End point:
Control: 3.29 (34)
Intervention groups
(combined result of
group 1, 2 and 3):
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Parents educated about their
child’s oral health care needs
and the upcoming operative
appointment verbally and
individualised illustration. The
flip chart had 3 separate pages
with drawings of the primary
definition showing the
progression of dental caries
from healthy teeth to pulpal
involvement. To standardise the
instruction, a prewritten script
about dental caries progression
of the primary teeth was read to
the parents, regardless of each
patient’s treatment needs, when
showing the flip chart
information.
Parents were also informed
about their children’s dental
treatment needs as they
watched the dental hygienist
draw the child’s treatment needs
on a pre-printed occlusal and
cross-sectional illustration of the
primary dentition (as seen in a
bitewing radiograph of the
primary dentition and the first
permanent molars) using red felt
tip pen.
Following the operative
appointment, the parents
responded to a post-operative
Outcome definitions
and method of
analysis
Results
Notes by review team
3.54 (110)
P value: .10
During extraction of
tooth
End point:
Control: 3.50 (8)
Intervention groups
(combined result of
group 1, 2 and 3):
3.62 (13)
P value: .71
During placement of
the restoration
End point:
Control: 3.47 (34)
Intervention groups
(combined result of
group 1, 2 and 3):
3.60 (113)
P value: .35
At dismissal from the
appointment End
point:
Control: 3.62 (37)
Intervention groups
(combined result of
group 1, 2 and 3):
3.68 (119)
P value: .61
Average behaviour
rating:
End point:
366
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
appointment survey, which
assessed their responses to
their child’s treatment. Each
dentist assessed the child
patient’s behaviour with the
Frankl behaviour rating scale at
6 points during the appointment:
1. When seated in the dental
chair, 2. During administration of
local anesthesia, 3. During
rubber dam placement, 4.
During decay excavation or
tooth extraction, 5. During
restoration placement and 6.
Upon dismissing the patient.
The Frankl behaviour scale: 1 =
“definitely negative”, 2 =
“negative”, 3 = “positive”, 4 =
“definitely positive”.
The dentists also recorded
whether the parent was present
in the operatory and whether
nitrous oxide was used.
Gingival and plaque scores
taken.
Theoretical basis: N/A
By whom: Dentist
To whom: Parents (and child)
How delivered: educated
verbally, plus standardised
visual tool (flip chart) and
individualised tool (illustration)
When/where: Paediatric dental
Outcome definitions
and method of
analysis
Results
Notes by review team
Control: 3.30 (33)
Intervention groups
(combined result of
group 1, 2 and 3):
3.54 (107)
P value: .04
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed
by group (i.e.
intervention vs
control): 30 families
(16%) failed to return
for their scheduled
operative
appointment
Conclusion:
Based on this study’s
results, the following
conclusions can be
made:
Compared to parents
who had been
informed with verbal
communication,
parents who received
illustrated information
about their child’s oral
health treatment
needs: a. were
significantly more
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
clinic
How often: Pre-op visit
(planning appointment) followed
by operative visit
How long for: Operative
appointment was less than 11
weeks following initial hygiene
and treatment planning
appointment. Whole study was
over 12 months
Control/Comparator
description:
What was delivered: Parents
undertook a baseline survey:
including questionnaires on
perceptions of their own oral
health, their children’s oral
health, and their dental fear;
knowledge about oral health and
their understanding of operative
treatment; perception of the
importance of the primary
dentition; and satisfaction with
the previous communication
about their children’s dental
treatment needs.
Outcome definitions
and method of
analysis
Results
Notes by review team
likely to return to an
operative dental
appointment with
their child; b. felt that
this information had
been more helpful to
prepare them for their
child’s operative visit;
and c. were less likely
to insist on being in
the operatory with
their child during the
operative visit.
Children of the
parents who had
received illustrated
information about
their child’s oral
health and treatment
needs behaved
significantly better
during the operative
appointment than
children whose
parents had received
traditional/verbal
information.
Parents educated about their
child’s oral healthcare needs
and the upcoming operative
appointment verbally without
any visual information being
provided. Following the
operative appointment, the
368
Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
parents responded to a postoperative appointment survey,
which assessed their responses
to their child’s treatment. Each
dentist assessed the child
patient’s behaviour with the
Frankl behaviour rating scale at
6 points during the appointment:
1. When seated in the dental
chair, 2. During administration of
local anesthesia, 3. During
rubber dam placement, 4.
During decay excavation or
tooth extraction, 5. During
restoration placement and 6.
Upon dismissing the patient.
The dentists also recorded
whether the parent was present
in the operatory and whether
nitrous oxide was used. Gingival
and plaque scores taken
By whom: Dentists
To whom: Parents (and child)
How delivered: Educated
verbally
When/where: Paediatric Dental
clinic
How often: Pre-op visit
(planning appointment) followed
by operative visit
How long for: Operative
appointment was less than 11
weeks following initial hygiene
and treatment planning
appointment. Whole study was
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
over 12 months
Sample size at baseline:
Total sample N = 189
Intervention group 1 N = NR
Intervention group 2 N = NR
Intervention group 3 N = NR
Control Group N = NR
Baseline comparisons (report
any baseline differences
between groups in important
confounders): Analysis was
undertaken to compare baseline
participants in all
intervention/control groups
(including demographic
background, own oral healthrelated characteristics,
perceptions of their child’s oral
health and oral health-related
behaviour, and knowledge and
attitudes concerning the
importance of their child’s
primary dentition and other oralhealth-related issues) - no
significant differences found
Study sufficiently powered
(power calculations and
provide details): NR
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
Author: Mike Wanless
Source
Population(s):
North West Region
of England
Study description:
What was delivered: The
members were asked to bring
along a resource which they
used frequently. This could be
a leaflet, poster, a resource
pack or training programme.
Outcomes (include
details of all
relevant outcome
measures and
whether measures
are objective or
subjective or
otherwise
validated):
Results:
Limitations
identified by
author:
Year: 2001
Citation: Wanless, W. (2001) An
audit of dental health education
material, International Journal of
Health Promotion and Education,
39:4, 106-108, DOI:
10.1080/14635240.2001.10806184
Country of study: England
Aim of Study: An audit of dental
health education materials
frequently used by community
dental services in the North West
of England is presented.
Resources were assessed for the
second edition of the Catalogue of
Dental Health Resources for
England, Wales and Northern
Ireland.
Study Design: Intervention
observational study. Assessment
techniques for dental health
materials used in an Inter-Trust
audit.
Quality Score (++, +, or -): -
Setting: Unclear
Location (urban
or rural): NR
Sample
characteristics:
Age: NR
Sex: NR
Sexual
orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of
residence: North
West of England
Occupation: Oral
health promoters,
dental service
managers and
community dental
officers
Education: NR
Socioeconomic
position:
Social capital:
External Validity(++, +, or -): +
Eligible
It was agreed to use the criteria
of Blinkhorn et al, rewritten as
standards:
1. The target group is clearly
indicated.
2. it is in agreement with the
Scientific Basis of Dental
Health Education and
Reports of the Committee
on Medical Aspects of
Food Policy
3. The aim is stated or selfevident.
4. The material addresses a
dental health problem
relevant to the target group.
5. The material presents a
positive image
6. It is understandable to the
target group
7. The illustrations are
appropriate.
The SMOG readability formula
was used to provide an
assessment of whether the
Outcome name:
Assessment of
resources
Outcome
definition:
Readability of the
resources which
were assessed
Outcome
measure:
Assessment
Outcome measure
validated: SMOG
was also used in
the Catalogue of
Dental Health
Education
Resources
Unit of
measurement:
score: standard not
achieved; standard
achieved;
improvement
1.Is the target
group clearly
defined:
Pre-discussions:
Standard not
achieved = 5
Standard achieved
= 19
Not applicable = 0
Post discussions:
Standard not
achieved = 0
Standard achieved
= 22
Improvement
beyond standard
already achieved =
0
Improvement but
standard not
achieved = 2
Not applicable = 0
2. Does it agree
with
SBDHE/COMA?
It was likely that
the time
constraints meant
that the reading
age was flagged
up as an area but
that people did not
have the
opportunity on the
day to
systematically
simplify the text.
Limitations
identified by
review team:
Time constraints
prevented the
readability being
assessed on all
the resources on
the day: 11 were
done on the day
and a further 7
were collected at
the end.
Pre-discussions:
Standard not
achieved = 5
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Study details
Population and
setting
Method of allocation to
intervention/control
population
(describe how
individuals,
groups, or
clusters were
recruited, e.g.
media
advertisement,
class list, area):
The Trusts in the
North West Region
of England
collaborate in a
number of InterTrust audits,
including oral
health promotion.
Oral health
promoters, dental
service managers
and community
dental officers
meet to audit an
aspect of the
service and
identify and
implement
improvements.
material was understandable to
the target group rather than rely
on subjective opinion, as was
used in the Catalogue of Dental
Health Education Resources.
An assessor explained the
principles of SMOG.
State if eligible
population is
considered by
the study authors
as representative
of the source
The formula calculates
readability using sentence and
word length and is
complementary to other criteria
including size and type of print,
layout and reader-based issues
such as previous knowledge.
The lower the score the easier
the piece is to read (however
low levels may appear childish).
The aim is to match the reading
level of the written material to
the reader’s level of reading
with understanding rather than
to reduce the score to the
minimum possible.
Theoretical basis: SMOG test
By whom: Members had the
standards explained to them
(by assessor?- unclear)
To whom: Members: Oral
health promoters, dental
service managers and
community dental officers
How delivered: Standards
explained, undertook a trial on
a commercially produced
Outcome
definitions and
method of
analysis
beyond standard
already achieved;
improvement but
standard not
achieved; not
applicable
Time points
measured: Pre and
post discussions
and improvements
(Table 1, p.107)
Results
Standard achieved
= 18
Not applicable = 1
Post discussions:
Standard not
achieved = 1
Standard achieved
= 20
Improvement
beyond standard
already achieved =
1
Improvement but
standard not
achieved = 1
Not applicable = 1
3. Is the aim
stated/selfevident?
Pre-discussions:
Standard not
achieved = 4
Standard achieved
= 20
Not applicable = 0
Notes by review
team
Evidence gaps:
Following the
audit exercise
some Trusts have
rewritten or
redesigned their
resources and
one is now
undertaking a
systematic review
of its oral health
promotion
resources using
the established
criteria. It is
intended that
there will be a
follow-up re-audit
so that any
improvement in
standards can be
monitored.
Source of
funding: NR
Post discussions:
Standard not
achieved = 1
Standard achieved
= 22
Improvement
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Study details
Population and
setting
Method of allocation to
intervention/control
population:
NR
leaflet, subsequent discussion.
Then assessed a resource of
their peers. Each standard was
assessed as having been
achieved, not achieved, or not
applicable. The groups then
discussed the resources and
agreed scoring and any
improvements. Then
reassessed it to reflect any
recommended improvements.
Members were also asked to
assess whether the resources
met individual Trust standards
(if known).
After improvements and
discussions the adapted
resources were assessed again
against the standards using five
codings: not achieved;
achieved; improvement beyond
standard already achieved;
improvement but standard not
achieved; not applicable.
When/where: North West
England – unclear where
How often: Once
How long for: NR
Inclusion Criteria:
Members of the
Trusts: Oral health
promoters, dental
service managers
and community
dental officers.
Exclusion
Criteria:
NR
% of selected
individuals
agreed to
participate:
NR
Potential sources
of bias:
As the resources
were selected by
the members,
some bias is
probable.
Sample size at baseline:
Total sample N = 24 resources
were assessed.
Outcome
definitions and
method of
analysis
Results
Notes by review
team
beyond standard
already achieved =
0
Improvement but
standard not
achieved = 1
Not applicable = 0
4. Does the
material address a
dental health
problem relevant
to the target
group?
Pre-discussions:
Standard not
achieved = 3
Standard achieved
= 21
Not applicable = 0
Post discussions:
Standard not
achieved = 1
Standard achieved
= 21
Improvement
beyond standard
already achieved =
0
Improvement but
standard not
achieved = 2
Not applicable = 0
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
5. Does the
material present a
positive image?
Pre-discussions:
Standard not
achieved = 5
Standard achieved
= 19
Not applicable = 0
Post discussions:
Standard not
achieved = 0
Standard achieved
= 19
Improvement
beyond standard
already achieved =
1
Improvement but
standard not
achieved = 4
Not applicable = 0
6. Is it
understandable to
the target group?
Pre-discussions:
Standard not
achieved = 6
Standard achieved
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
= 18
Not applicable = 0
Post discussions:
Standard not
achieved = 1
Standard achieved
= 19
Improvement
beyond standard
already achieved =
1
Improvement but
standard not
achieved = 3
Not applicable = 0
7. Are the
illustrations
appropriate?
Pre-discussions:
Standard not
achieved = 6
Standard achieved
= 16
Not applicable = 2
Post discussions:
Standard not
achieved = 0
Standard achieved
= 18
Improvement
beyond standard
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
already achieved =
1
Improvement but
standard not
achieved = 4
Not applicable = 1
The pre-exercise
mean SMOG score
was 14.2, with a
range from 11 to
16. 4 were scored
by the groups after
being amended and
another 3 were
rewritten but not
scored at the time.
The pre-exercise
score for these 7
was a mean of
14.0, with a range
from 12 to 16. After
amendment it was
13.2, with a range
from 11 to 14.5.
Thus only a small
decrease in SMOG
score was actually
achieved. It is likely
that the time
constraints meant
that reading age
was flagged up as
an area but that
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Oral Health: Approaches for general practice teams on promoting oral health
Study details
Population and
setting
Method of allocation to
intervention/control
Outcome
definitions and
method of
analysis
Results
Notes by review
team
people did not have
the opportunity on
the day to
systematically
simplify the text.
Conclusion:
No conclusion
given except:
The criteria as
described by
Holloway et al
provided an
excellent framework
for an audit
exercise which all
the responding
participants
considered to be
enjoyable, useful
and relevant.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
Author: Weinstein,
P., R. Harrison, and
T. Benton
Source
Population(s):
Country of study
(include if developed
or non-developed)
Method of allocation (Describe
how selected
individuals/clusters were
allocated to intervention or
control groups – state if not
reported): Table of random
numbers used. In addition the
children were stratified into 2
age groups (6 to 12 months and
older than 12 months) for each
sex. The age stratification was
used to account for individual
differences in the number of
erupted teeth and the time of
exposure to cariogenic foods.
We used sex stratification to
account for any parenting
differences that may have
affected caries risk.
Outcomes (include
details of all relevant
outcome measures and
whether measures are
objective or subjective
or otherwise validated):
Oral health (clinical)
results:
Outcome name:
Caries
Outcome definition:
New carious lesions
Outcome measure:
Visual examinations
using a modification of
the criteria of Radike.
Calibrated examiner
(either author or local
dentist)
Outcome measure
validated: Unclear
% of groups (no
information on actual
numbers provided):
Limitations identified
by author:
Compared 2
treatments – did not
have a placebo control
group.
Cost effectiveness not
assessed
All parents in the study
were volunteers – it
may not be possible to
generalise the results
to entire populations.
Year: 2004 (Paper
One); Paper Two
(2006)
Citation:
Weinstein, P., R.
Harrison, and T.
Benton, Motivating
parents to prevent
caries in their young
children: one-year
findings. Journal of
the American Dental
Association, 2004.
135(6): p. 731-8.
(Paper One)
Weinstein, P., R.
Harrison, and T.
Benton, Motivating
mothers to prevent
caries: confirming
the beneficial effect
of counselling.
Journal of the
American Dental
Association, 2006.
137(6): p. 789-93.
(Paper Two)
Country of study:
Infants aged 6 to 18
months and their
mothers from a South
Asian Punjabispeaking community
in Surrey (Canada).
Setting: Setting of
intervention is unclear.
Population was
chosen because
children of South
Asian immigrants are
at high risk of
developing ECC.
Location (urban or
rural): NR
Sample
characteristics:
Age: Infants 6 to 18
months
Sex: NR
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Report how confounding
factors were minimised: No
significant differences between
the intervention and control
group were identified at the
baseline with the exception of
age. This was controlled for in
the logistic regression model
that was undertaken. No
information was provided on
blinding or contamination.
Programme/Intervention
description:
Unit of measurement:
NR
Children with new
Decayed or Filled
Surfaces (DFS):
Intervention group(s):
Baseline: 0%
Year 1 followup:15.2%
Year 2 follow-up:
35.2%
Control group(s)
Baseline: 0%
Year 1 follow-up:26%
Year 2 follow-up:52%
Time points
measured: Annually
(for 2 years)
Difference between
groups at Year 1 was
2
significant: χ = 5.67,
P< 0.02, two sided
Outcome name:
Behaviour
Outcome definition:
Parenting practices
were assessed, as well
as dietary and hygiene
practices that affect
NOTE: While the
chart on page 792 of
Paper 2 indicates that
the percentage of
children with DFS at
baseline was zero,
page 735 (para.4) of
Limitations identified
by review team:
The source population
is not well described in
terms of demographics
and there is no
information to test
whether the sample is
representative, or
whether refusals
amongst the eligible
population may have
prejudiced the sample.
As the control group
received a leaflet and
video intervention
there was no usual
practice group to
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Study details
Population and
setting
Method of allocation to
intervention/control
Canada
Religion: NR
Place of residence:
NR
Occupation: NR
Education: NR
Socioeconomic
position: NR
Social capital: NR
What was delivered: Parents in
the experimental group received
the same pamphlet and video
(as the control group), as well as
one 45 minute counselling
session.
Theoretical basis: Motivational
Interviewing for behavioural
change
By whom: Local South Asian
women were trained and
conducted motivational
interviewing
To whom: No additional
information
How delivered: Written
(pamphlet) and visual (video)
and Motivational Interviewing
session. Pamphlet and video
were modified to include dietary
and non-dietary ECC-preventive
strategies appropriate to the
local South Asian community.
MI was used to establish rapport
with the patients, present and
discuss a menu of oral hygiene
options with them.
When/where: NR
How often: Patients received:
initial visit, followed by 2 followup telephone calls at 2 weeks
and one month after initial
contact. Parents were then
called 4 times during
maintenance period and 2
Aim of Study:
Paper One:
To compare the
effect of a
motivational
interviewing
counselling
treatment with that
of traditional health
education on
parents of young
children at high risk
of developing dental
caries.
Paper Two:
The purpose of this
study was to
compare the effect
of a motivational
interviewing (MI)
counselling visit with
traditional health
education for
mothers of young
children at high risk
of developing dental
caries. The aim of
this article is to
provide additional
evidence of the
efficacy of MI with
mothers of young
Eligible population
(describe how
individuals, groups, or
clusters were
recruited, e.g. media
advertisement, class
list, area): Recruited
by visiting temples
and fairs in the South
Asian Punjabispeaking community
in Surrey (Canada).
State if eligible
population is
considered by the
study authors as
representative of the
source population:
NR – as the method of
recruitment was
based on visiting
temples and fairs it is
unlikely to be
representative in any
statistically significant
sense. The women
Outcome definitions
and method of
analysis
ECC
Outcome measure:
Each parent completed
2 interview schedules
used in previous
studies. In addition 2
instruments were used
to assess parenting
practices.
Outcome measure
validated: Unclear
Unit of measurement:
NR
Time points
measured: Annually
(for 2 years)
Although behaviour is
reported as an outcome
in both papers they do
not present any results
and both say the results
of these measures will
be published
elsewhere.
Method of analysis
(indicate if ITT or
completer analysis was
used and if adjustments
were made for any
baseline differences in
important confounders):
Results
Notes by review team
Paper One states that
2 children in the
intervention group
and 4 in the control
group had carries at
baseline.
compare the
intervention with.
After controlling for
age and number of
fluoride varnish visits
in year 2 the
protective effect of MI
after 2 years had not
diminished (Odds
Ratio=37, CI = 0.76
to 1.76).
Caries surfaces
after one year
1 year findings:
Intervention group:
Mean:0.71
Standard
deviation:2.8
Range:0-25
Control group:
Mean:1.91
Standard
deviation:4.8
Range:0-25
Difference between
groups at Year 1 was
The use of follow-up
calls in the intervention
group means that it is
difficult to ascertain
whether it was the
counselling that
explained the
difference in results
from the control, or the
reminders made during
the maintenance
period. This is a
serious weakness.
It is not clear whether
the intervention was
delivered in a dental
clinic or not. It is
possible it was
delivered at a
community centre
which limits the
applicability of the
findings to this study.
The results of the
intervention on the
behavioural outcome
are not reported in
either paper although
they are said to be
reported elsewhere.
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Study details
Population and
setting
Method of allocation to
intervention/control
children after 2
years of follow-up.
recruited are more
likely to be those who
are active in those
places and may differ
from the overall
population in terms of
social class,
occupation or religion
amongst other factors.
postcard reminders were sent.
How long for: Actual length of
time from the counselling
session to the second follow-up
call was just one month.
However this extends to a total
of 6 months after initial contact if
maintenance period is included.
Study Design: RCT
– allocation by
individual
Quality Score (++,
+, or -): External
Validity(++, +, or -):
+
Inclusion Criteria:
NR
Exclusion Criteria:
Excluded if a history
of a serious acute or
chronic disease that
would interfere with
ability of the child and
parent to participate
fully
% of selected
individuals agreed to
participate: NR – all
participants were
volunteers
Potential sources of
bias:
Control/Comparator
description:
What was delivered: Each
subject in the control group
received a pamphlet designed
by the staff of the local health
unit and also viewed a video
called “Preventing Tooth Decay
for Infants and Toddlers”. This
11 minute educational video
was available in five languages,
including Punjabi, and was
produced by the
Vancouver/Richmond Health
Board with the advice of one of
the investigators
By whom: Leaflet designed by
the staff of the local government
health unit. Video produced by
the Vancouver/Richmond Health
Board
To whom: No additional
information
How delivered: Written
(pamphlet) and visual (video).
Pamphlet and video were
Outcome definitions
and method of
analysis
Results
Notes by review team
significant: t[238]=
2.37, one-tailed,
P<0.01
Evidence gaps: No
additional research
suggested.
Logistic regression
analysis of caries
incidence – suggest
that both age (Odds
ratio=1.080,
CI=1.014-1.150
p=0.016) and
treatment (Odds
Ratio= 1.927,
CI=0.967-3.842,
p=0.062) had an
effect, but sex did
not.
Source of funding:
The study was
supported by grant
P60 DE13061 from the
National Institutes of
Health, National
Institute of Dental and
Craniofcial Research,
Bethesda, Md
Behavioural results:
These are not
presented in either
paper and both state
that they are
published elsewhere.
Attrition details:
Indicate the number
lost to follow up and
whether the
proportion lost to
follow-up differed by
group (i.e.
intervention vs
control)
After 2 years in the
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
modified to include dietary and
non-dietary ECC-preventive
strategies appropriate to the
local South Asian community
When/where: NR
How often: Unclear – annual
assessments over a 2 year
period but intervention may only
have been once
How long for: 11 minute video.
trial 205 (85%) of the
240 children were
available for follow-up
dental examination.
There is no
information on the
breakdown of these
numbers by group.
Sample size at baseline:
Results suggest that
MI counselling has an
effect on children’s
health that is greater
than the effect of
traditional health
education.
Total sample N = 240
Intervention group N = NR
Control Group N = NR
Baseline comparisons (report
any baseline differences
between groups in important
confounders): No significant
differences were found between
the groups in terms of
demographic variables (such as
child’s sex, mother’s marital
status, mother’s time in Canada,
mother’s rural or urban status,
mother’s residence history and
number of household members);
perinatal factors, child health
parameters; or exposure to
fluoride supplements, antibiotics
and vitamins. Differences in
caries status and unerupted
dentition were not significant.
The only significant difference
Notes by review team
Conclusion:
MI presents promise
in working with the
parents of young
children to prevent
caries in those
children, especially
children at high risk of
developing the
disease.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review team
was in age (see note on the
minimisation of confounding
factors above).
Study sufficiently powered
(power calculations and provide
details):NR
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Study Details
Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
Author: M Williams
and J Bethea
Study design: Mixed
methods
Research aims,
objectives, and
questions:
The purpose of this paper is
to determine the extent of
patient awareness of a
combined poster and leaflet
campaign providing
opportunistic information
about the risks of smoking
and excess alcohol
consumption t o patients
whose lifestyle habits place
them at risk of developing
oral cancer. (p.1 (para.3)
and p.2 (para.1))
Brief description of method and
process of analysis [including
analytic and data collection
technique]:
Initially face-to-face interviews were
conducted but as initial uptake was very
poor, the study team amended the
protocol and offered participants the
option to be interviewed over the
telephone. Of the 9 interviews that were
completed, 2 were done face-to-face and
7 were conducted over the telephone. All
interviews were audio-taped and
transcribed verbatim. Thematic analysis
was undertaken by the researcher and
the analysis and interpretations were
verified by a second researcher with
experience of qualitative research
methods. (p.3 para.2)
Limitations identified by
author:
Year: 2011
Population the sample
was recruited from: All
patients aged 18 years and
th
over attending within 5
st
November 2007- 21
th
December 2008 and 19
th
May 2008 to 11 July 2008.
(p.2 para.2)
Citation: Williams, M.
and J. Bethea,
Patient awareness of
oral cancer health
advice in a dental
access centre: a
mixed methods study.
British Dental Journal,
2011. 210(6): p. E9.
Country of study:
England
(Nottinghamshire)
Quality Score (++, +,
or -): +
Theoretical approach
[grounded theory, IPA
etc]:
State how data were
collected:
What method(s): Mixed
methods approach. Data
were collected during 2 time
periods in line with the
poster campaign being run
at the Integrated Dental
Unit. Mouth cancer information leaflets provided by
Cancer Research UK were
displayed in the patient
How sample was
recruited: As it was
anticipated that uptake to
the interview phase of the
study would be low, a true
purposive approach to
sampling could not be
taken and instead all
patients who returned their
contact details to the
researcher were
interviewed. (p.3 para.2)
How many participants
recruited: 1161 (89.7% of
1294 patients asked)
provided quantitative data
to triage nurse and were
split into groups. 424 of
these came under the
“High” or “Very High”
groups from which patients
were recruited for
interviews. (p.2 Table 1 and
p.3 para.3) 9 recruited for
interviews. (p.3 para.2)
Quantitative results – Awareness of
poster and leaflet campaign
All groups:
Read at least some of the information:
535 (46.1%)
Read poster only: 392 (37.8% of 1036)
Read leaflet only : 47 (4.5% of 1033)
Read poster and leaflet: 25 (2.4% of
1038) (p.2 Table 2)
The number reporting having read any of
the information in each consumption
group did not differ significantly, with
48.6% (261 of 537) of those in the low
consumption group reporting having read
Firstly, of the 1,294 patients
who were eligible to
participate in the study,
data on consumption were
available for 1,161 (89.7%).
Data were not collected for
all participants for a variety
of reasons, for example, in
a small number of cases
the triage nurses felt the
patient was too distressed
to answer the questions
relating to consumption and
whether or not they had
taken notice of the
information campaign. In
the majority of cases,
however, data were
excluded because the data
sheets were not fully or
accurately completed. An
analysis of this missing
data showed that cases not
included were not different
in terms of age or sex, with
the median ages of
excluded and included
cases being very similar (33
years and 32 years) and a
similar proportion of
excluded cases being
female (45% of excluded
cases compared to 39% of
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Oral Health: Approaches for general practice teams on promoting oral health
Study Details
Research Parameters
waiting areas of the IDU
together with a number of
A4 posters with bullet-point
facts about oral cancer.
Patients were asked by the
triage nurse if they had read
the information provided as
part of the information
campaign (p.2 para.2)
Information provided by
patients regarding their
alcohol and tobacco
consumption was used to
place them into one of 4
groups:
1. Low tobacco and
alcohol use group: nonsmokers who either do
not drink alcohol or
drink less than 20 units
per week
2. Moderate tobacco and
alcohol use group:
smokers who do not
drink alcohol and who
smoke up to 20
cigarettes per day
3. High tobacco and
alcohol use group:
smokers who consume
up to 20 cigarettes per
day and drink up to 20
units of alcohol per
week
4. Very high consumption
group: smokers using in
Population and Sample
Selection
Sample characteristics –
Quantitative element
(1,161 patients who
provided information on
consumption):
Age: 32 years (median)
Sex: 57.2% were men
Sexual orientation: NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence: NR
Occupation: NR
Education: NR
Socioeconomic position:
NR
Social capital: NR
Sample characteristics –
Qualitative element (9
interview respondents):
Age: 2 female participants
were considerably younger
(22 years) than others who
ranged from 36 to 58 years
of age
Sex: 5 were male and 4
were female
Sexual orientation: NR
Disability: NR
Ethnicity: All ‘White British’
Religion: NR
Place of residence: NR
Occupation: NR
Education: NR
Socioeconomic position:
NR
Outcomes and Methods of Analysis
Notes by Review Team
at least some information, compared with
44.1% (160 of 363) of those in the high
consumption group (Chi-square = 2.73,
df = 3, p = 0.44). (p.3 para.4)
included cases). (p.5 para
6)
Quantitative results – Reasons for not
reading the information
Of the 338 who did give a reason
Didn’t see/ take notice of it: 199 (58.9%)
In too much pain to read: 36 (10.7%)
Not English speaking: 20 (5.9%)
Reading other material: 13 (3.8%)
Can’t see (no glasses) to read: 12 (3.6%)
Ex-smoker: 11 (3.3%)
Busy texting/ chatting: 9 (2.7%)
Looking after child: 8 (2.4%)
No time, seen straight away: 8 (2.4%)
Not a drinker or a smoker: 6 (1.8%)
Too far away from posters to read: 6
(1.8%)
Can’t read: 3 (0.9%)
Too nervous: 3 (0.9%)
Learning disability 2 (0.6%)
Sleeping: 1 (0.3%)
Did not wait in waiting area: 1 (0.3%) (p.2
Table 3)
Qualitative results – Key themes and
findings relevant to this review [with
illustrative quotes if available]
Knowledge and perceptions about the
disease:
 Although all but one of the
participants stated that they had
read the information leaflet
Some data were also
missing for why participants
had not read any of the
information available. Again
in a small number of cases
the triage nurses felt it was
inappropriate to ask the
patients any further
questions due to their pain,
but in the majority of cases
the data sheets were not
fully completed. This is
likely to reflect a degree of
operator fatigue as the
triage nurses were asked to
complete the forms over a
relatively long period.
However, those who
weren’t asked why they had
not read the information
were very similar to both
those who had given an
answer and participants
overall in terms of sex, age
and consumption (median
age of 32 and 38% female,
low consumption 41% moderate 20% high or very high
39%). (p.5 para 7)
Limitations identified by
review team:
The initial baseline
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Study Details
Research Parameters
excess of 20 cigarettes
per day, and/or drinking
in excess of 20 units of
alcohol per week (p.2
para.2)
Patients in the high and
very high consumption
groups were asked if they
would participate in an
interview with a researcher
to explore their knowledge
and beliefs about risk
factors shown to be linked
with oral cancer (p.2 para.3)
Population and Sample
Selection
Social capital: NR
Inclusion criteria (for
qualitative interview
element): Patients
classified under with the
‘very high’ or ‘high’
consumption groups – see
note on methods used.
[criteria for quantitative
element is the same as
population from which
sample were recruited]
Outcomes and Methods of Analysis


Exclusion criteria: NR
Patients interested in
participating were provided
with an information pack
that included a description
of the study, consent form
and contact details. (p.3
para.1)
By whom: Triage nurse
asked about consumption.
Researcher then did
interviews. (p.2 para.2
and3)
What setting: Integrated
Dental Unit – these provide
emergency dental care so
not quite sure about
eligibility (p.2 para.2)
When: Poster campaign 5
November 2007-21
December 2007, and 19
May 2008-11 July 2008 (p.2

overall knowledge about the
disease was limited and most
reported that they knew nothing
at all (p.3 para.6)
When prompted most thought
smoking would put them at
increased risk largely because
smoking was generally related to
cancer risk (p.3 para.8)
Respondents retained very little
information – they knew little
about prevalence and when age
of onset was reported it was
described as being ‘older’ (p.3
para.10)
Few felt they knew the signs and
symptoms they should be
looking for that might indicate
oral cancer (p.3 para.10)
Risk factors and risk-taking
behaviour:
 Although most thought that
smoking put them at risk of oral
cancer – less than half knew
that alcohol consumption had
any association with oral cancer
risk (p.3 para.12)
 3 respondents had picked up
that alcohol was a risk factor
from the leaflet but overall
respondents were surprised that
alcohol consumption was linked
to oral cancer (p.4 para.1)
 Although all of the respondents
knew or at least suspected that
Notes by Review Team
assessment of
alcohol/tobacco
consumption which
included questions on
readership of the leaflet
was undertaken with a
large majority of patients
(89.7%). The rationale for
undertaking qualitative
research with those
patients who came under
the "very high" and "high"
consumption categories is
clear. However the authors
admit that they were unable
to undertake purposive
sampling for the qualitative
stage because they were
aware that the response
rate was likely to be poor.
Given the initial sample was
very large (424 in eligible
groups according to Table
1) and an incentive was
used its not clear why the
response rate was so poor
(just 9 respondents).
The authors point out that
not all the data sheets for
the quantitative element
were completed. While this
was partly due to
completely legitimate
ethical reasons it was
mainly due to operator
fatigue. For the qualitative
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Study Details
Research Parameters
para.2)
Population and Sample
Selection
Outcomes and Methods of Analysis
their smoking status put them at
increased risk only one
participant reported that this
knowledge would actually
impact on their behaviour (p.4
para.4)
Profile of the disease:
 Most of the patients did not have
a regular dentist either due to
limited availability or because of
the cost associated with
treatment (p.4 par 7)
 The respondents felt that oral
cancer didn’t have the same
profile as other cancers (p.4
para.9)
Health messages:
Respondents gave a range of
suggestions related to how key
messages should best be relayed:
 Providing information in nonhealth (in addition to health)
settings – such as pubs, clubs,
job centres, day centres – was
considered important. (p.4
para.12)
 In health settings including
dental surgeries the sheer
volume of health messages
provided was thought to reduce
impact – one participant felt
bombarded by health messages
and another felt that books and
magazines provided in dental
Notes by Review Team
interviews the researchers
had to change their tactics
and include telephone
interviews instead of faceto-face interviews for some
participants. It is not clear
whether the impact of using
a different data collection
on participant responses
(particularly given the
differences in 'interviewer
effects') has was taken into
account.
The setting is clear and
there is information on
some respondent
characterstics. Some
information on education,
income level and ethnicity
(given some of the
respondents did not read
the leaflet due to limited
English) would have been
useful.. However given the
difficulties with data
collection it may not have
been feasible to collect
such information. Context
bias does not appear to
have been considered -as
respondents may have
claimed to have read some
of the leaflet to please the
triage nurse.
Reliability of the methods is
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis



settings were a distraction that
should be got rid of (p.4 paras
12-15)
Television and media campaigns
were generally considered to be
an effective way of relaying key
information on cancers (p.4
para.16)
Some of the participants talked
about having the key information
relayed to them by a health
professional as part of a
consultation either because
written information was not
accessible to those with low
levels of literacy or because it
would have more impact than
having the information provided
alone (p.4 para.19)
Issues such as cost and
accessibility to those who work
during office hours were also
raised (p.4 para.19)
Conclusions:
In this study, approximately 40% of
patients in the target groups read the
information available. Disappointingly, it
would seem that even after reading the
information available, patients’
knowledge of risk factors remains poor,
and this suggests that the impact of
presenting information in this format in
the dental access centre will be limited.
Other studies have demonstrated that
Notes by Review Team
poor. Although 2 methods
were used they generally
dealt with different
questions - the quant
focussed on what
information the patients had
read and the qual on what
information they had
retained and how best
information had been
provided. Given that by far
the most common reason
for not reading the patient
information in the waiting
room was because patients
"didn't see/take notice of it"
- it might hve been useful to
explore what was meant by
this response in more detail
in the qualitative interviews.
The quantitative analysis
was reasonably
straightforward. More
information could have
been provided on how the
qualitative data was coded
into themes.
Differences related to age
and gender weren't really
explored but given the size
of the sample this would
have been difficult. Age and
gender was noted against
each of the quotes used. It
would have been uiseful to
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
patient information leaflets are effective
in increasing patient knowledge and
awareness of risks related to oral cancer.
p.12, para.25–27 These studies have
involved patients attending medical and
dental practices for routine care, have
tested patient knowledge immediately
after reading the information leaflet, and
were not specifically targeted at high-risk
individuals. In addition, patients were
handed the information leaflet by the
researcher. In this study the poster
directed patients to the leaflets for
additional information, but were taken up
by only a few patients. (p.5 para.4)
know which were telephone
and which were face-toface interviewees so the
context is clear.
Of those patients giving a reason for not
reading the information, the majority
(almost 60%) had not seen or did not
notice the posters or leaflets. This might
improve with changes in the visual
impact of the material. Similarly, the
availability of information in a multilingual
format, tailored to local community
needs, may encourage uptake of
information. Just over 10% did not read
the information because of pain, and this
will always be a difficulty in providing the
information in this format to patients that
have very immediate dental problems.
(p.5 para.9)
Although based on a relatively small
number the qualitative element does
provide some evidence that the provision
of information through a simple poster
and leaflet format is likely to have limited
There is no mention of any
procedures to ensure
reliability of the analysis of
the quantitative element.
For the qualitative element
a second researcher
verified the analysis and
interpretations.
Extracts from the original
data are included and the
finidngs are clearly
presented. Table 2 contains
different sample sizes for
different questions from
which percentages are
calculated. This may be
due to non-response to
some items. In the limitation
section the authors point
out that data sheets were
often not fully completed
due to operator fatigue
(though in a minority of
cases there were sound
ethical reasons for not
continuing). However it isn't
made clear that this is the
cause.
Evidence gaps and/or
recommendations for
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Research Parameters
Population and Sample
Selection
Outcomes and Methods of Analysis
Notes by Review Team
impact. It is known that patients in this
high-risk cohort can be extremely difficult
to influence and so health promotion in
this group might pose significant
challenges. Social marketing
approaches, which involve developing an
in-depth knowledge and understanding
of the behaviour and beliefs of the target
group, have been shown to be effective
in promoting health behaviour change
Such approaches might then also be
useful in developing health promotion
campaigns around oral cancer. p.5
para.10 and p.6 para.1.
future research: Dental
access centres should play
a significant role in primary
prevention but the way in
which patient information is
provided requires further
investigation. Primary Care
Trusts should invest in the
development and provision
of effective measures within
dental access centres to
provide opportunistic
information about the risks
of smoking and excess
alcohol consumption to
targeted cohorts of patients.
(p.6 para.3)
Source of funding: Cancer
Research UK provided the
leaflets but it is not clear
which body provided
funding for the rest of the
study.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
Results
Notes by review
team
Author: Witton,
R.V., Moles, D.R.
Source
Population(s):
Dentists in UK
Method: Between February
and June 2011 all 508
health service general
dentists registered to
practice in the NHS in
Devon were sent a
questionnaire. Their names
and practice (dental office)
addresses were obtained
from a local health service
database.
Outcome name:
Barriers and Facilitators
Questionnaire score
Outcome definition: A
pre-validated barriers
and facilitators
questionnaire was
selected from the
literature chosen for its
focus on prevention
guidelines
Outcome measure:
Barriers and Facilitators
Questionnaire
Outcome measure
validated: Yes - prevalidated
Examples of barriers and
facilitators were evident at
various organisational
levels of dentistry. These
were principally the
healthcare system,
practice (dental office)
arrangements, and
professional factors.
Limitations
identified by author:
The response rate of
52% was
disappointing
although this rate is
consistent with other
questionnaire based
studies of health
professionals. The
results may therefore
be subject to selection
bias. There is no
demographic data
available locally to
compare the profile of
responders to the
sampling frame and
so the results must be
interpreted with
caution as the issues
identified here may
not be representative
of other dentists
locally or nationally in
England. Another
factor that is relevant
to the response rate
and with due
consideration to the
study aims is the
possibility that failure
to respond to the
questionnaire may
have been the result
Year: 2013
Citation: Witton,
R.V., Moles, D.R.
(2013) Barriers and
facilitators that
influence the delivery
of prevention
guidance in health
service dental
practice: a
questionnaire study
of practising dentists
in Southwest
England. Community
Dental Health. 2013
Jun;30(2):71-6
Aim of Study: To
investigate and
identify barriers and
facilitators that
influence the
implementation of
prevention guidance
by health service
dentists practicing in
Devon, South West
England.
Study Design: Selfcompletion
Setting: Devon,
South West England;
Type of practice n,
[%]:
Urban: 77 [31]
Rural: 59 [24]
Mixed: 111 [45]
Sample
characteristics:
Age: 24-69 (mean
42, SD 11)
Sex: 56% male
Sexual orientation:
NR
Disability: NR
Ethnicity: NR
Religion: NR
Place of residence:
UK
Occupation: Health
service general
dental practitioners;
45% mixed NHS and
Private practice; 75%
spent at least half of
their time providing
NHS dental care
Education: 43%
qualified for more
than 20 years;
Each recipient received a
questionnaire to complete, a
pre-paid return envelope, an
information sheet explaining
the purpose of the research,
and a covering letter
explaining why they had
been chosen. Measures
reported in the literature to
increase the completion and
response rates of
questionnaires were
followed. In addition, the
support of local dental
representative committees
was obtained to encourage
a high response rate.
Each dentist received 2
mailings of the
questionnaire, 2 weeks
apart giving a 4 week
window to return the
Data were collected via
37 items, with each
item using a 5-point
Likert scale so
respondents could rate
their level of agreement
from ‘fully agree’ to
‘fully disagree’
organised in 3 principal
domains:
Implementation of
‘Delivering better oral
health’;
‘Delivering Better Oral
Health’ leaves enough
Implementation of
‘Delivering better oral
health’
Overall respondents gave
positive responses to
questions concerning the
flexibility (53%) and benefit
of the guideline (63%) and
they tended to disagree
they had problems
changing their old routines
(58%).
Opinion was divided
among respondents on
whether they felt patients
followed their advice
(49%) and whether they
had support from the local
health service in
implementing the guideline
(51% ‘fully
disagreed’/’disagreed’ that
no support was available).
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Study details
Population and
setting
Method of allocation to
intervention/control
questionnaire
Socioeconomic
position: NR
Social capital:NR
questionnaire. Return of the
questionnaire was taken as
assent to the process.
Inclusion Criteria:
NR
Sample size at baseline:
253 questionnaires were
returned (246 fully
completed, 7 incomplete)
Quality Score (++,
+, or -): +
External
Validity(++, +, or -):
+
Exclusion Criteria:
NR
Power analysis: NR
Outcome definitions
and method of
analysis
room for me to make
my own decisions
‘Delivering Better Oral
Health’ laves me
enough room to weigh
up the wishes of the
patient
‘Delivering Better Oral
Health’ is a good
starting point for my
self-study of preventive
dentistry
I did not thoroughly
read ‘Delivering Better
Oral Health’
I do not remember
receiving ‘Delivering
Better Oral Health’
I wish to know more
about the content
before I decide to apply
it
I have problems
changing my old
routines
I think parts of
‘Delivering Better Oral
Health’ are incorrect
Results
32% felt that to implement
the guideline they required
additional funding,
whereas only 12%
opposed this view with the
remainder having no
strong opinion. Responses
to the remaining questions
were mixed with no clear
pattern of agreement or
disagreement.
Implementation of
prevention in general
There was overall
agreement that delivering
prevention in practice is
problematic if there are
insufficient staff (68%),
facilities (53%), and time
(60%).
Most respondents reported
feeling adequately trained
to deliver preventive
guidance (59%). Opinion
was roughly evenly divided
between respondents on
the difficulties of providing
preventive care to patients
from: different cultural
backgrounds (32% overall
agreed, and 32%
disagreed); that seem
Notes by review
team
of a lack of awareness
of the guideline, or a
failure to take the
guideline seriously.
There is some
evidence for this in
the questionnaire
responses discussed
but also in the fact
that a number of
questionnaires were
returned for this
reason or were
defaced. This
highlights a potential
fundamental primary
barrier to participating
in the study and
strengthens the
argument that passive
dissemination of
clinical guidelines is
not an effective
strategy to safeguard
their implementation
in clinical practice.
Limitations
identified by review
team:
Only frequencies were
reported. Further
analyses could have
provided more depth.
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Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
I have a general
resistance to working
according to protocols
Fellow dentists (general
practitioners) do not cooperate in applying the
guidance
Other members of the
dental team (therapists,
hygienists, nurses etc)
do not cooperate in
applying the guidance
The Primary Care Trust
do not support
implementation of the
guideline
Patients do not cooperate with the advice
in the guidance
Working to ‘Delivering
Better Oral Health’ is
too time consuming
The guidance does not
fit into my ways of
working at my practice
Working according to
this guidance requires
financial compensation
Results
healthy (49% overall
agreed, and 32%
disagreed); of low socioeconomic status (42%
overall agreed, and 41%
disagreed); or older
patients (47% overall
agreed, and 37%
disagreed).
Attrition details:
Of the 266 questionnaires
returned, 246 (92%) were
fully completed, 7 were
incomplete (3%), and 13
were either defaced or
unusable (5%). 204
questionnaires were not
returned (40%), and a
further 38 (7%) were
returned to sender
because the dentists were
no longer practicing at the
address given by the local
health service database.
Notes by review
team
Evidence gaps:
There are very few
comparative data in
the dental literature
with which to compare
the results of this
study. A further
qualitative study is
planned to investigate
in more depth the
reasons underpinning
the responses given.
Source of funding:
NR
Conclusion:
The study has identified
some barriers and
facilitators to the delivery
of prevention guidance in
this group of health service
dentists with no one factor
seemingly more important
than another.
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
The layout of
‘Delivering Better Oral
Health’ makes it easy
to use
Results
Notes by review
team
Implementation of
prevention in general
“It is difficult to give
preventive care…”
If there are not enough
support staff
If resources needed are
not available
Because the timing of
preventive care id
difficult to fit into
treatment plans
If physical space is
lacking (e.g. oral health
education room)
Because I am not
trained in giving
evidence-based
preventive care
Because I have not
been involved in setting
up preventive care
policies in the practice
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Study details
Population and
setting
Method of allocation to
intervention/control
Outcome definitions
and method of
analysis
To patients with a
different cultural
background
Results
Notes by review
team
To patients who seem
healthy
To patients with a low
socio-economic status
To older patients (60+)
Demographic details
Method of analysis:
Frequency analyses
were carried out to
describe respondent
characteristics and
demographics.
394
Oral Health: Approaches for general practice teams on promoting oral health
5. References Included in the Review
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individually tailored oral health educational programme on oral hygiene behaviour in patients
with periodontal disease: a blinded randomised-controlled clinical trial (one-year follow-up).
Journal of Clinical Periodontology, 36(12), 1025-1034. doi: 10.1111/j.1600-051X.2009.01453.
2. Jonsson, B., Ohrn, K., Lindberg, P., and Oscarson, N. (2012). Cost-effectiveness of an
individually tailored oral health educational programme based on cognitive behavioural
strategies in non-surgical periodontal treatment. Journal of Clinical Periodontology, 39(7),
659-665.
3. Jönsson, B., Öhrn, K., Lindberg, P., and Oscarson, N. (2010). Evaluation of an individually
tailored oral health educational programme on periodontal health. Journal of Clinical
Periodontology, 37(10), 912-919. doi: 10.1111/j.1600-051X.2010.01590.x
4.Jönsson, B.,Öhrn, K., Oscarson, N., and Lindberg, P. (2009) An individually tailored
treatment programme for improved oral hygiene: introduction of a new course of action in
health education for patients with periodontitis. International Journal of Dental Hygiene, 7(3),
166-175.
5. Münster Halvari, A. E., Halvari, H., Bjørnebekk, G., and Deci, E. L. (2012). Selfdetermined motivational predictors of increases in dental behaviours, decreases in dental
plaque, and improvement in oral health: A randomised clinical trial. Health Psychology, 31(6),
777-788. doi: http://dx.doi.or.g/10.1037/a0027062
6.Kakudate, N., Morita, M., Sugai, M., and Kawanami, M. (2009). Systematic cognitive
behavioural approach for oral hygiene instruction: a short-term study. Patient Education and
Counseling, 74(2), 191-196.
7. Clarkson, J. E., Young, L., Ramsay, C. R., Bonner, B. C., and Bonetti, D. (2009). How to
influence patient oral hygiene behaviour effectively. Journal of Dental Research, 88(10),
933-937.
8.Little, S. J., Hollis, J. F., Stevens, V. J., Mount, K., Mullooly, J. P., and Johnson, B. D.
(1997). Effective group behavioural intervention for older periodontal patients. Journal of
Periodontal Research, 32(3), 315-325.
9. Fjellstrom, M., Yakob, M., Soder, B. (2010) A modified cognitive behavioural model as a
method to improve adherence to oral hygiene instructions--a pilot study. International
Journal of Dental Hygiene, 8(3), 178-82.
10.Kasila, K., Poskiparta, M., Kettunen, T., and Pietila, I. (2006). Oral health counselling in
changing schoolchildren's oral hygiene habits: a qualitative study. Community Dentistry and
Oral Epidemiology, 34(6), 419-428.
11.Kasila, K., Poskiparta, M., Kettunen, T., and Pietila, I. (2008). Variation in assessing the
need for change of snacking habits in schoolchildren's oral health counselling. International
Journal of Paediatric Dentistry, 18(2), 107-116.
12. Hugoson, A., Lundgren, D., Asklow, B., and Borgklint, G. (2003). The effect of different
dental health programmes on young adult individuals. A longitudinal evaluation of knowledge
and behaviour including cost aspects. Swedish Dental Journal, 27(3), 115-130.
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13. Blinkhorn, A. S., Gratrix, D., Holloway, P. J., Wainwright-Stringer, Y. M., Ward, S. J., and
Worthington, H. V. (2003). A cluster randomised, controlled trial of the value of dental health
educators in general dental practice. British Dental Journal, 195(7), 395-400; discussion 385.
14. Hausen, H., Seppa, L., Poutanen, R., Niinimaa, A., Lahti, S., Karkkainen, S., and Pietila,
I. (2007). Noninvasive control of dental caries in children with active initial lesions. A
randomised clinical trial. Caries Research, 41(5), 384-391.
15. Hugoson, A., Lundgren, D., Asklow, B., and Borgklint, G. (2007). Effect of three different
dental health preventive programmes on young adult individuals: a randomised, blinded,
parallel group, controlled evaluation of oral hygiene behaviour on plaque and gingivitis.
Journal of Clinical Periodontology, 34(5), 407-415.
16.Lepore, L. M., Yoon, R. K., Chinn, C. H., and Chussid, S. (2011). Evaluation of behaviour
change goal-setting action plan on oral health activity and status. New York State Dental
Journal, 77(6), 43-47.
17. Weinstein, P., Harrison, R., and Benton, T. (2004). Motivating parents to prevent caries
in their young children: one-year findings. Journal of the American Dental Association,
135(6), 731-738.
18. Weinstein, P., Harrison, R., and Benton, T. (2006). Motivating mothers to prevent caries:
confirming the beneficial effect of counseling. Journal of the American Dental Association,
137(6), 789-793.
19. Jonsson, B., Lindberg, P., Oscarson, N., and Ohrn, K. (2006). Improved compliance and
self-care in patients with periodontitis--a randomised control trial. International Journal of
Dental Hygiene, 4(2), 77-83.
20.Wang, S. J., Briskie, D., Hu, J. C., Majewski, R., and Inglehart, M. R. (2010). Illustrated
information for parent education: parent and patient responses. Pediatric Dentistry, 32(4),
295-303.
21.Humphris, G. M., and Field, E. A. (2003). The immediate effect on knowledge, attitudes
and intentions in primary care attenders of a patient information leaflet: a randomised control
trial replication and extension. British Dental Journal, 194(12), 683-688; discussion 675.
22. Humphris, G. M., and Field, E. A. (2004). An oral cancer information leaflet for smokers
in primary care: results from two randomised controlled trials. Community Dentistry and Oral
Epidemiology, 32(2), 143-149.
23. Humphris, G. M., Freeman, R., and Clarke, H. M. (2004). Risk perception of oral cancer
in smokers attending primary care: a randomised controlled trial. Oral Oncology, 40(9), 916924.
24.Humphris, G. M., Ireland, R. S., and Field, E. A. (2001). Immediate knowledge increase
from an oral cancer information leaflet in patients attending a primary health care facility: a
randomised controlled trial. Oral Oncology, 37(1), 99-102.
25.Humphris, G. M., Ireland, R. S., and Field, E. A. (2001). Randomised trial of the
psychological effect of information about oral cancer in primary care settings. Oral Oncology,
37(7), 548-552.
396
Oral Health: Approaches for general practice teams on promoting oral health
26. Boundouki, G., Humphris, G., and Field, A. (2004). Knowledge of oral cancer, distress
and screening intentions: longer term effects of a patient information leaflet. Patient
Education and Counseling, 53(1), 71-77.
27.Lees, A., and Rock, W. P. (2000). A comparison between written, verbal, and videotape
oral hygiene instruction for patients with fixed appliances. Journal of Orthodontics, 27(4),
323-328.
28. Wanless, M. B. (2001). An audit of dental health education material. International Journal
of Health Promotion and Education, 39(4), 106-108.
29. Ashford, R. A. (1998). An investigation of male attitudes toward marketing
communications from dental service providers. British Dental Journal, 184(5), 235-238.
30..Vachirarojpisan, T., Shinada, K., and Kawaguchi, Y. (2005). The process and outcome of
a programme for preventing early childhood caries in Thailand. Community Dental Health,
22(4), 253-259. http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/603/CN00532603/frame.html
31. O'Hara, D. M., Seagriff-Curtin, P., Levitz, M., Davies, D., and Stock, S. (2008). Using
Personal Digital Assistants to improve self-care in oral health. Journal of Telemedicine and
Telecare, 14(3), 150-151.
32.Sbaraini, A., and Evans, R. W. (2008). Caries risk reduction in patients attending a caries
management clinic. Australian Dental Journal, 53(4), 340-348.
33. Holloway, P. J., and Clarkson, J. E. (1994). Cost: benefit of prevention in practice.
International Dental Journal, 44(4), 317-322.
34. Threlfall, A. G., Hunt, C. M., Milsom, K. M., Tickle, M., and Blinkhorn, A. S. (2007).
Exploring factors that influence general dental practitioners when providing advice to help
prevent caries in children. British Dental Journal, 202(4), E10; discussion 216-217.
35.Threlfall, A. G., Milsom, K. M., Hunt, C. M., Tickle, M., and Blinkhorn, A. S. (2007).
Exploring the content of the advice provided by general dental practitioners to help prevent
caries in young children. British Dental Journal, 202(3), E9; discussion 148-149.
36. Witton, R. V., and Moles, D. R. (2013). Barriers and facilitators that influence the delivery
of prevention guidance in health service dental practice: a questionnaire study of practising
dentists in Southwest England. Community Dental Health, 30(2), 71-76.
37. Harris, R. V., Dailey, Y. M., and Ireland, R. S. (2002). General dental practitioner advice
regarding the use of fluoride toothpaste in two areas with a school-based milk fluoridation
programme and one without such a programme. British Dental Journal, 193(9), 529-533;
discussion 519.
38. Ashkenazi, M., Kessler-Baruch, O., and Levin, L. (2014). Oral hygiene instructions
provided by dental hygienists: results from a self-report cohort study and a suggested
protocol for oral hygiene education. Quintessence International, 45(3), 265-269.
39.Jensen, O., Gabre, P., Skold, U. M., Birkhed, D., and Povlsen, L. (2014). 'I take for
granted that patients know' - oral health professionals' strategies, considerations and
methods when teaching patients how to use fluoride toothpaste. International Journal of
Dental Hygiene, 12(2), 81-88.
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40. Meurman, P., Pienihakkinen, K., Eriksson, A. L., and Alanen, P. (2009). Oral health
programme for preschool children: a prospective, controlled study. International Journal of
Paediatric Dentistry, 19(4), 263-273.
41.Poole, J., Conte, C., Brewer, C., Good, C. C., Perella, D., Rossie, K. M., and Steen, V.
(2010). Oral hygiene in scleroderma: The effectiveness of a multi-disciplinary intervention
program. Disability and Rehabilitation, 32(5), 379-384. doi:
http://dx.doi.org/10.3109/09638280903171527
42. Grant, E., Carlson, G., and Cullen-Erickson, M. (2004). Oral health for people with
intellectual disability and high support needs: Positive outcomes. Special Care in Dentistry,
24(2), 70-79.
43. Levesque, M. C., Dupere, S., Loignon, C., Levine, A., Laurin, I., Charbonneau, A., and
Bedos, C. (2009). Bridging the poverty gap in dental education: how can people living in
poverty help us? Journal of Dental Education, 73(9), 1043-1054.
44.Loignon, C., Allison, P., Landry, A., Richard, L., Brodeur, J. M., and Bedos, C. (2010).
Providing humanistic care: dentists' experiences in deprived areas. Journal of Dental
Research, 89(9), 991-995. doi: 10.1177/0022034510370822
45.Rajabiun, S., Fox, J. E., McCluskey, A., Guevara, E., Verdecias, N., Jeanty, Y., Mofidi, M.
(2012). Patient perspectives on improving oral health-care practices among people living
with HIV/AIDS. Public Health Reports, 127(SUPPL.2), 73-81.
46. Schouten, B. C., Eijkman, M. A., and Hoogstraten, J. (2003). Dentists' and patients'
communicative behaviour and their satisfaction with the dental encounter. Community Dental
Health, 20(1), 11-15.
47. Brocklehurst, P., Bridgman, C., and Davies, G. (2013). A qualitative evaluation of a Local
Professional Network programme "Baby Teeth DO Matter". Community Dental Health, 30(4),
241-248.
48. Dyer, T. A., and Robinson, P. G. (2006). General health promotion in general dental
practice--the involvement of the dental team Part 2: A qualitative and quantitative
investigation of the views of practice principals in South Yorkshire. British Dental Journal,
201(1), 45-51; discussion 31.
49. Arora, R. (2000). Message framing and credibility: application in dental services. Health
Marketing Quarterly, 18(1-2), 29-44.
50. Williams, M., and Bethea, J. (2011). Patient awareness of oral cancer health advice in a
dental access centre: a mixed methods study. British Dental Journal, 210(6), E9.
51. Mills, I., Frost, J., Kay, E., Moles, D. Measuring patient experience – A model of person
centred care in dentistry (submitted to British Dental Journal)
52. Ostberg, A. L. (2005). Adolescents' views of oral health education. A qualitative study.
Acta Odontol Scand, 63(5), 300-307.
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6. Bibliography
Adult Dental Health Survey 2009. The Health and Social Care Information Centre 2011.
NHS
Cancer incidence in the UK in 2011, Cancer Research UK 2014
Child dental health survey 2003. The Health and Social Care Information Centre 2005. NHS
Dental quality and outcomes framework DH 2011
Department of Heath, 2007. Valuing people’s oral heath: A good practice guide for improving
the oral health of children and adults
Department of Health and British Association for the Study of Community Dentistry (2009)
Delivering better oral health: an evidence-based toolkit for prevention. London: Department
of Health
Harris, R., Gamboa, A., Dailey, Y., & Ashcroft, A. (2012). One-to-one dietary interventions
undertaken in a dental setting to change dietary behaviour. Cochrane Database of
Systematic Reviews, (3)
Improving dental care and oral health – call to action NHS England 2014
Kay, E., & Locker, D. (1998). A systematic review of the effectiveness of health promotion
aimed at improving oral health (Structured abstract). Community Dental Health, 15(3), 132144.
Khokhar Waqqas, A., Clifton, A., Jones, H., & Tosh, G. (2011). Oral health advice for people
with serious mental illness. Cochrane Database of Systematic Reviews, (11).
Levine RS, Stillman-Lowe CR (2009) The scientific basis of oral health education: sixth
edition. London: British Dental Journal
Local authorities improving oral health: commissioning better oral health for children and
young people – an evidence informed toolkit for local authorities Public Health England 2014
National Dental Epidemiology Programme for England, Oral health survey of 5 year old
children 2012. Public Health England 2013
NHS dental statistics for England 2012–13 Health and Social Care Information Centre 2013
Oral health and access to dental services for people from black and minority ethnic groups
Race Equality Foundation 2013
Public Health England 2014
Rayner J, Holt R, Blinkhorn F et al. (2003) British Society of Paediatric Dentistry: A policy
document on oral health care in preschool children. International Journal of Paediatric
Dentistry 13: 279–85
Yevlahova, D., and Satur, J. (2009) Models for individual oral health promotion and their
effectiveness: a systematic review. Australian Dental Journal, 54: 190-197
399
Oral Health: Approaches for general practice teams on promoting oral health
Appendix A Search Strategy
The following search strategy was developed for Ovid Medline and adapted as necessary for
the additional databases used in the review:
1
Health Education, Dental/ (5770)
2
((dental or oral) adj3 (health or hygiene or care) adj3 (educat$ or promot$ or
program$ or outreach$ or instruct$ or teach$ or message$ or advice or counsel$ or
intervention$ or information or advise$ or campaign$ or initiative$ or strateg$)).ti.
(2634)
3
(dental$ adj3 (promot$ or program$ or outreach or instruct$ or advice or message$ or
counsel$ or intervention$ or information or advise$ or campaign$ or initiative$ or
strateg$)).ti. (2546)
4
Oral Hygiene/ed [Education] (409)
5
Oral Health/ed [Education] (59)
6
Oral Hygiene/ and (educat$ or promot$ or program$ or outreach$ or instruct$ or
teach$ or message$ or advice or counsel$ or intervention$ or information or advise$ or
campaign$ or initiative$ or strateg$).ti. (1105)
7
Oral Health/ and (educat$ or promot$ or program$ or outreach$ or instruct$ or
teach$ or message$ or advice or counsel$ or intervention$ or information or advise$ or
campaign$ or initiative$ or strateg$).ti. (1034)
8
Public Health Dentistry/ or Community Dentistry/ (3573)
9
exp Preventive Dentistry/ (29720)
10 ((dentist$ or dental) and ((public adj3 health) or (community adj3 health) or (community
adj3 (program$ or project$)))).tw. (3880)
11 ((dentist$ or dental) and (health adj2 (general or public))).ti. (941)
12 ((dentist$ or dental) adj4 ((early adj intervention$) or (early adj diagnos$) or
prevent$)).tw. (5952)
13 (dentist$ or dental).tw. and (exp public assistance/ or medicaid.tw.) (1207)
14 exp Periodontal Diseases/pc [Prevention and Control] (5869)
15 exp Tooth Diseases/pc [Prevention and Control] (21896)
16 Oral Hygiene/ (10390)
17 Oral Health/ (10329)
18 ((Oral or dental) adj3 (health or hygiene or care)).tw. (39081)
19 (toothbrush$ or floss$ or interdental or dental or dentist$ or dentition or tooth or teeth or
mouthwash$ or mouthrins$ or toothpaste$ or dentifrice$ or caries or periodont$ or
gingiv$).tw. (339249)
20 ((caries or periodont$) and (prevent$ or control$)).ti. (4246)
21 exp Health Promotion/ (54632)
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Oral Health: Approaches for general practice teams on promoting oral health
22 Patient Education as Topic/ (70529)
23 Health Education/ (52351)
24 Health Communication/ (604)
25 Information Dissemination/ (10325)
26 Persuasive Communication/ (2993)
27 exp Educational Technology/ (86784)
28 exp "Tobacco Use Cessation"/mt (7443)
29 exp Substance-Related Disorders/ed, pc [Education, Prevention and Control] (18106)
30 exp Diet/ed [Education] (12)
31 ((health or prevention or preventive) adj3 (promot$ or educat$ or instruct$ or advice or
program$ or outreach or communicat$ or information or message$ or counsel$ or
intervention$ or advise$ or campaign$ or initiative$ or strateg$)).ti. (53765)
32 exp Dental Staff/ (2251)
33 exp Dentists/ (15250)
34 dental auxiliaries/ or dental assistants/ or dental hygienists/ or dental staff/ (12136)
35 ((dental adj (nurse$ or assistant$ or (care adj professional$) or hygienist$ or
therapist$ or (surgery adj assistant$) or auxiliar$ or staff$ or (health adj educator$) or
(practice adj manager$) or receptionist$)) or (oral adj health adj educator$)).tw. (4620)
36 exp dental care/ (25546)
37 Group Practice, Dental/ or Partnership Practice, Dental/ or General Practice, Dental/ or
Practice management, Dental/ (15274)
38 (Dental adj5 (practice$ or clinic or clinics or office$ or facility or facilities)).tw. (16041)
39 exp Dental Facilities/ (7868)
40 (Case reports, or clinical trial, all or comparative study or interview or meta analysis or
multicenter study or observational study or systematic reviews or review).pt. (5282046)
41 (randomi$ or quantitat$ or qualitat$ or placebo or randomly or (control adj3 (area or
cohort$ or compare$ or condition or design or group$ or intervention$ or
participant$ or study))).tw. (1606278)
42 (Trial or (multicent$ or multi-cent$) or pilot or review$ or follow-up or (follow$ adj up$) or
outcome$ or study or studies or design or designs or research or ethnograph$ or
intervention$ or observation$ or case or evaluat$ or monitor$ or program$ or
model$ or process or interview or interviews or (mixed adj method$)).tw. (11185457)
43 exp empirical research/ (22700)
44 40 or 41 or 42 or 43 (13568394)
45 exp Nursing/ (222496)
46 (midwife$ or midwives or ((geriatric or (occupational adj health) or orthop*edic or
p*ediatric or psychiatric or (public adj health) or school or oncology or nephrology) adj
(nurse or nurses))).tw. (29247)
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Oral Health: Approaches for general practice teams on promoting oral health
47 (p*ediatrician$ or obstetrician$ or doctor$ or oncologist$ or forens$ or (intensive adj
care) or (critical adj care) or (family adj physician$) or technician$ or laborator$).tw.
(671560)
48 45 or 46 or 47 (895229)
49 1 or 2 or 3 or 4 or 5 or 6 or 7 (9619)
50 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (358351)
51 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 (313435)
52 50 and 51 (8842)
53 49 or 52 (15304)
54 32 or 33 or 34 or 35 (26962)
55 36 or 37 or 38 or 39 (55606)
56 54 or 55 (74454)
57 53 and 56 (4836)
58 57 not 48 (4663)
59 animals/ not humans/ (3874907)
60 58 not 59 (4662)
61 limit 60 to english language (4004)
62 limit 61 to yr="1994 -Current" (2490)
63 44 and 62 (1818)
402
Oral Health: Approaches for general practice teams on promoting oral health
Appendix B Quality Assessment Checklists
Quality Assessment Checklist for Intervention Studies
Study identification: (Include full citation
details)
Study design:
Refer to the glossary of study designs (appendix
D) and the algorithm for
classifying experimental and observational
study designs (appendix E) to best describe the
paper's underpinning study design
Guidance topic:
Assessed by:
Section 1: Population
Rating (++ + - NR N/A)
Comments
1.1 Is the source population or source area well
described?
Was the country (e.g. developed or nondeveloped, type of healthcare
system), setting (primary schools, community
centres etc.), location
(urban, rural), population demographics etc.
adequately described?
1.2 Is the eligible population or area
representative of the source
population or area?
Was the recruitment of individuals, clusters or
areas well defined (e.g.
advertisement, birth register)?
Was the eligible population representative of the
source? Were important
groups under-represented?
1.3 Do the selected participants or areas
represent the eligible
population or area?
Was the method of selection of participants from
the eligible population
well described?
What % of selected individuals or clusters
agreed to participate? Were
there any sources of bias?
Were the inclusion or exclusion criteria explicit
and appropriate?
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Section 2: Method of allocation to
intervention (or comparison)
Rating (++ + - NR N/A)
Comments
2.1 Allocation to intervention (or comparison).
How was selection
bias minimised?
Was allocation to exposure and comparison
randomised? Was it truly
random ++ or pseudo-randomised + (e.g.
consecutive admissions)?
If not randomised, was significant confounding
likely (−) or not (+)?
If a cross-over, was order of intervention
randomised?
2.2 Were interventions (and comparisons) well
described and
appropriate?
Were interventions and comparisons described
in sufficient detail (i.e.
enough for study to be replicated)?
Was comparisons appropriate (e.g. usual
practice rather than no
intervention)?
2.3 Was the allocation concealed?
Could the person(s) determining allocation of
participants or clusters to
intervention or comparison groups have
influenced the allocation?
Adequate allocation concealment (++) would
include centralised allocation
or computerised allocation systems
2.4 Were participants or investigators blind to
exposure and
comparison?
Were participants and investigators – those
delivering or assessing the
intervention kept blind to intervention allocation?
(Triple or double blinding
score ++)
If lack of blinding is likely to cause important
bias, score −
2.5 Was the exposure to the intervention and
comparison adequate?
Is reduced exposure to intervention or control
related to the intervention
(e.g. adverse effects leading to reduced
compliance) or fidelity of
implementation (e.g. reduced adherence to
protocol)?
Was lack of exposure sufficient to cause
important bias?
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2.6 Was contamination acceptably low?
Did any in the comparison group receive the
intervention or vice versa?
If so, was it sufficient to cause important bias?
If a cross-over trial, was there a sufficient washout period between
interventions?
2.7 Were other interventions similar in both
groups?
Did either group receive additional interventions
or have services provided
in a different manner?
Were the groups treated equally by researchers
or other professionals?
Was this sufficient to cause important bias?
2.8 Were all participants accounted for at study
conclusion?
Were those lost-to-follow-up (i.e. dropped or lost
pre-,during or postintervention)
acceptably low (i.e. typically <20%)?
Did the proportion dropped differ by group? For
example, were drop-outs
related to the adverse effects of the
intervention?
2.9 Did the setting reflect usual UK practice?
Did the setting in which the intervention or
comparison was delivered differ
significantly from usual practice in the UK? For
example, did participants
receive intervention (or comparison) condition in
a hospital rather than a
community-based setting?
2.10 Did the intervention or control comparison
reflect usual UK
practice?
Did the intervention or comparison differ
significantly from usual practice in
the UK? For example, did participants receive
intervention (or comparison)
delivered by specialists rather than GPs? Were
participants monitored
more closely?
Section 3: Outcomes
Rating (++ + - NR N/A)
Comments
3.1 Were outcome measures reliable?
Were outcome measures subjective or objective
(e.g. biochemically
validated nicotine levels ++ vs self-reported
smoking −)?
How reliable were outcome measures (e.g.
inter- or intra-rater reliability
scores)?
Was there any indication that measures had
been validated (e.g. validated
against a gold standard measure or assessed
for content validity)?
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3.2 Were all outcome measurements complete?
Were all or most study participants who met the
defined study outcome
definitions likely to have been identified?
3.3 Were all important outcomes assessed?
Were all important benefits and harms
assessed?
Was it possible to determine the overall balance
of benefits and harms of
the intervention versus comparison?
3.4 Were outcomes relevant?
Where surrogate outcome measures were used,
did they measure what
they set out to measure? (e.g. a study to assess
impact on physical
activity assesses gym membership – a
potentially objective outcome
measure – but is it a reliable predictor of
physical activity?)
3.5 Were there similar follow-up times in
exposure and comparison
groups?
If groups are followed for different lengths of
time, then more events are
likely to occur in the group followed-up for
longer distorting the
comparison.
Analyses can be adjusted to allow for
differences in length of follow-up
(e.g. using person-years).
3.6 Was follow-up time meaningful?
Was follow-up long enough to assess long-term
benefits or harms?
Was it too long, e.g. participants lost to followup?
Section 4: Analyses
Rating (++ + - NR N/A)
Comments
4.1 Were exposure and comparison groups
similar at baseline? If
not, were these adjusted?
Were there any differences between groups in
important confounders at
baseline?
If so, were these adjusted for in the analyses
(e.g. multivariate analyses or
stratification).
Were there likely to be any residual differences
of relevance?
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4.2 Was intention to treat (ITT) analysis
conducted?
Were all participants (including those that
dropped out or did not fully
complete the intervention course) analysed in
the groups (i.e. intervention
or comparison) to which they were originally
allocated?
4.3 Was the study sufficiently powered to detect
an intervention
effect (if one exists)?
A power of 0.8 (that is, it is likely to see an effect
of a given size if one
exists, 80% of the time) is the conventionally
accepted standard.
Is a power calculation presented? If not, what is
the expected effect size?
Is the sample size adequate?
4.4 Were the estimates of effect size given or
calculable?
Were effect estimates (e.g. relative risks,
absolute risks) given or possible
to calculate?
4.5 Were the analytical methods appropriate?
Were important differences in follow-up time
and likely confounders
adjusted for?
If a cluster design, were analyses of sample
size (and power), and effect
size performed on clusters (and not
individuals)?
Were subgroup analyses pre-specified?
4.6 Was the precision of intervention effects
given or calculable?
Were they meaningful?
Were confidence intervals or p values for effect
estimates given or
possible to calculate?
Were CI's wide or were they sufficiently precise
to aid decision-making? If
precision is lacking, is this because the study is
under-powered?
Section 5: Summary
Rating (++ + - NR N/A)
Comments
5.1 Are the study results internally valid (i.e.
unbiased)?
How well did the study minimise sources of bias
(i.e. adjusting for potential
confounders)?
Were there significant flaws in the study design?
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5.2 Are the findings generalisable to the source
population (i.e.
externally valid)?
Are there sufficient details given about the study
to determine if the
findings are generalisable to the source
population? Consider:
participants, interventions and comparisons,
outcomes, resource and
policy implications.
408
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Quality Assessment Checklist for Non-Intervention Quantitative Studies
Study identification: (Include full citation
details)
Study design:
Refer to the glossary of study designs (appendix
D) and the algorithm for
classifying experimental and observational
study designs (appendix E) to best describe the
paper's underpinning study design
Guidance topic:
Assessed by:
Section 1: Population
Rating (++ + - NR N/A)
Comments
Rating (++ + - NR N/A)
Comments
1.1 Is the source population or source area well
described? Was the country (e.g. developed or
non-developed, type of healthcare system),
setting (primary schools, community centres
etc.), location (urban, rural), population
demographics etc. adequately described?
1.2 Is the eligible population or area
representative of the source population or area?
Was the recruitment of individuals, clusters or
areas well defined (e.g. advertisement, birth
register)? Was the eligible population
representative of the source? Were important
groups under-represented?
1.3 Do the selected participants or areas
represent the eligible population or area? Was
the method of selection of participants from the
eligible population well described? What % of
selected individuals or clusters agreed to
participate? Were there any sources of bias?
Were the inclusion or exclusion criteria explicit
and appropriate?
Section 2: Method of allocation to
intervention (or comparison)
2.1 Selection of exposure (and comparison)
group. How was selection bias minimised? How
was selection bias minimised?
2.2 Was the selection of explanatory variables
based on a sound theoretical basis? How sound
was the theoretical basis for selecting the
explanatory variables?
2.3 Was the contamination acceptably low? Did
any in the comparison group receive the
exposure?
If so, was it
sufficient to cause important bias?
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2.4 How well were likely confounding factors
identified and controlled? Were there likely to be
other confounding factors not considered or
appropriately adjusted for? Was this sufficient to
cause important bias?
Section 3: Outcomes
Rating (++ + - NR N/A)
Comments
Rating (++ + - NR N/A)
Comments
3.1 Were outcome measures and procedures
reliable? Were outcome measures subjective or
objective (e.g. biochemically validated nicotine
levels ++ vs self-reported smoking −)? How
reliable were outcome measures (e.g. inter- or
intra-rater reliability scores)? Was there any
indication that measures had been validated
(e.g. validated against a gold standard measure
or assessed for content validity)?
3.2 Were all outcome measurements complete?
Were all or most study participants who met the
defined study outcome definitions likely to have
been identified?
3.3 Were all important outcomes assessed?
Were all important benefits and harms
assessed? Was it possible to determine the
overall balance of benefits and harms of the
intervention versus comparison?
3.4 Was there a similar follow-up time in
exposure and comparison groups? If groups are
followed for different lengths of time, then more
events are likely to occur in the group followedup for longer distorting the comparison.
Analyses can be adjusted to allow for
differences in length of follow-up (e.g. using
person-years).
3.5 Was follow-up time meaningful? Was followup long enough to assess long-term benefits or
harms? Was it too long, e.g. participants lost to
follow-up?
Section 4: Analyses
4.1 Was the study sufficiently powered to detect
an intervention effect (if one exists)? A power of
0.8 (that is, it is likely to see an effect of a given
size if one exists, 80% of the time) is the
conventionally accepted standard. Is a power
calculation presented? If not, what is the
expected effect size? Is the sample size
adequate?
4.2 Were multiple explanatory variables
considered in the analyses? Was there
sufficient explanatory variables considered in
the analysis?
4.3 Were the analytical methods appropriate?
Were important differences in follow-up time
and likely confounders adjusted for?
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4.4 Was the precision of association given or
calculable? is association meaningful? Were
confidence intervals or p values for effect
estimates given or possible to calculate? Were
CI's wide or were they sufficiently precise to aid
decision-making? If precision is lacking, is this
because the study is under-powered?
Section 5: Summary
Rating (++ + - NR N/A)
Comments
5.1 Are the study results internally valid (i.e.
unbiased)?
How well did the study minimise sources of bias
(i.e. adjusting for potential
confounders)?
Were there significant flaws in the study design?
5.2 Are the findings generalisable to the source
population (i.e.
externally valid)?
Are there sufficient details given about the study
to determine if the
findings are generalisable to the source
population? Consider:
participants, interventions and comparisons,
outcomes, resource and
policy implications.
411
Oral Health: Approaches for general practice teams on promoting oral health
Quality Assessment Checklist for Qualitative Studies
Study identification: (Include full citation
details)
Study design:
Refer to the glossary of study designs (appendix
D) and the algorithm for
classifying experimental and observational
study designs (appendix E) to best describe the
paper's underpinning study design
Guidance topic:
Assessed by:
Section 1: Theoretical Approach
Rating (++ + - NR N/A)
Comments
Rating (++ + - NR N/A)
Comments
1.1 Is a qualitative approach appropriate? For
example:
Does the research question seek to understand
processes or structures, or illuminate subjective
experiences or meanings? Could a quantitative
approach better have addressed the research
question?
[Appropriate / Inappropriate / Not sure]
1.2 Is the study clear in what it seeks to do?
For example:
Is the purpose of the study discussed aims/objectives/research question/s?
Is there adequate/appropriate reference to the
literature?
Are underpinning values/assumptions/theory
discussed?
[Clear / Unclear / Mixed]
Section 2: Study Design
2.1 How defensible/rigorous is the research
design/methodology? For example:
Is the design appropriate to the research
question? Is a rationale given for using a
qualitative approach? Are there clear accounts
of the rationale/justification for the sampling,
data collection and data analysis techniques
used?
Is the selection of cases/sampling strategy
theoretically justified?
[Defensible / Indefensible / Not sure]
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Oral Health: Approaches for general practice teams on promoting oral health
Section 3: Data collection
Rating (++ + - NR N/A)
Comments
Rating (++ + - NR N/A)
Comments
3.1 How well was the data collection carried
out?
For example:
Are the data collection methods clearly
described?
Were appropriate data collected to address the
research question?
Was the data collection and record keeping
systematic?
[Appropriately / Inappropriately / Not sure or
inadequately reported]
Section 4. Trustworthiness
4.1 Is the role of the researcher clearly
described?
For example:
Has the relationship between the researcher
and the participants been adequately
considered?
Does the paper describe how the research was
explained and presented to the participants?
[Clearly described / Unclear / Not described]
4.2 Is the context clearly described?
For example:
Are the characteristics of the participants and
settings clearly defined?
Were observations made in a sufficient variety
of circumstances?
Was the context bias considered?
[Clear / Unclear / Not sure]
4.3 Were the methods reliable?
For example:
Was data collected by more than 1 method?
Is there justification for triangulation, or for not
triangulating?
Do the methods investigate what they claim to?
[Reliable / Unreliable / Not sure]
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Oral Health: Approaches for general practice teams on promoting oral health
Section 5: Analyses
Rating (++ + - NR N/A)
Comments
5.1 Is the data analysis sufficiently rigorous?
For example:
Is the procedure explicit - i.e. is it clear how the
data was analysed to arrive at the results?
How systematic is the analysis, is the procedure
reliable/dependable?
Is it clear how the themes and concepts were
derived from the data?
[Rigorous / Not rigorous / Not sure or not
reported]
5.2 Is the data rich?
For example:
How well are the contexts of the data
described?
Has the diversity of perspective and content
been explored?
How well has the detail and depth been
demonstrated?
Are responses compared and contrasted across
groups/sites?
[Rich / Poor / Not sure or not reported]
5.3 Is the analysis reliable?
For example:
Did more than one researcher theme and code
transcripts/data?
Is so, how were differences resolved?
Did participants feed back on the
transcripts/data if possible and relevant?
Were negative/discrepant results addressed or
ignored?
[Reliable / Unreliable / Not sure or not reported]
5.4 Are findings convincing?
For example:
Are the findings clearly presented?
Are the findings internally coherent?
Are extracts from the original data included?
Are the data appropriately referenced?
Is the reporting clear and coherent?
[Convincing / Not convincing / Not sure]
5.5 Are the findings relevant to the aims of the
study?
[Relevant / Irrelevant / Partially relevant]
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Oral Health: Approaches for general practice teams on promoting oral health
5.6 Conclusions
For example:
How clear are the links between data.
Interpretation and conclusions?
Are the conclusions plausible and coherent?
Have alternative explanations been explored
and discounted?
Does this enhance understanding of the
research topic?
Are the implications of the research clearly
defined?
Is there adequate discussion of any limitations
encountered?
[Adequate / Inadequate / Not sure]
Section 6: Ethics
Rating (++ + - NR N/A)
Comments
Rating (++ + - NR N/A)
Comments
6.1 How clear and coherent is the reporting of
ethics?
For example:
Have ethical issues been taken into
consideration?
Are they adequately discussed e.g. do they
address consent and anonymity? Have the
consequences of the research been considered
i.e. raising expectations, changing behaviour?
Was the study approved by an ethics
committee?
[Appropriate / Inappropriate / Not sure or not
reported]
Section 7: Overall Assessment
As far as can be ascertained from the paper,
how well was the study conducted?
Grade according to:
++ All or most of the checklist criteria have been
fulfilled, where they have not been fulfilled the
conclusions are very unlikely to alter.
+ Some of the checklist criteria have been
fulfilled, where they have not been fulfilled, or
not adequately described, the conclusions are
unlikely to alter.
- Few or no checklist criteria have been fulfilled
and the conclusions are likely or very likely to
alter
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Oral Health: Approaches for general practice teams on promoting oral health
Appendix C Details of Excluded Studies
Ramos-Gomez F. (2012) Early Maternal
Exposure to Children's Oral Health may be
Correlated with Lower Early Childhood Caries
Prevalence in Their Children. Journal of
Evidence-Based Dental Practice. 12: p. 29-31.
Review of the study, not the
actual study
Almomani, F., et al., Effects of an oral health
promotion program in people with mental
illness. Journal of Dental Research, 2009.
88(7): p. 648-52.
Not in Dental practice setting
Anderson, R., E.T. Treasure, and A.S. Sprod,
Oral health promotion practice: A survey of
dental professionals in Wales. International
Journal of Health Promotion and Education,
2002. 40(1): p. 9-14.
provides general information on
percentage of advice are given
but nothing about effectiveness
and barriers/facilitators
Arora, A., et al., 'English leaflets are not meant
for me': a qualitative approach to explore oral
health literacy in Chinese mothers in
Southwestern Sydney, Australia. Community
Dentistry and Oral Epidemiology, 2012. 40(6):
p. 532-541.
Not in a dental practice setting
Bolden, A.J. and H.L. Logan, Differences in
judgments of persuasive argument quality by
three population groups in Iowa. Journal of
Public Health Dentistry, 1995. 55(1): p. 18-21.
Not in a dental practice
Brand, V., et al., Impact of single-session
motivational interviewing on clinical outcomes
following periodontal maintenance therapy.
International Journal of Dental Hygiene, 2013.
11(2): p. 134-141.
Not in a dental practice setting –
academic health centre dental
clinic
Buglar, M.E., K.M. White, and N.G. Robinson,
The role of self-efficacy in dental patients’
brushing and flossing: Testing an extended
Health Belief Model. Patient Education and
Counseling, 2010. 78(2): p. 269-272.
Not an oral health promotion
intervention
Cibulka, N.J., et al., Improving oral health in
low-income pregnant women with a nurse
practitioner-directed oral care program. Journal
of the American Academy of Nurse
Practitioners, 2011. 23(5): p. 249-257.
Not in a dental practice setting
Clarkson, J.E., et al., IQuaD dental trial;
improving the quality of dentistry: a multicentre
randomised controlled trial comparing oral
hygiene advice and periodontal instrumentation
for the prevention and management of
periodontal disease in dentate adults attending
dental primary care. BMC Oral Health, 2013.
13: p. 58.
Study protocol - not full trial –
no outcomes reported
416
Oral Health: Approaches for general practice teams on promoting oral health
Cornell, P.J., S. Richards, and S. Westlake,
Does informing patients about the link between
dental hygiene and rheumatoid arthritis
encourage better dental care? Arthritis and
Rheumatism, 2011. 1).
Not in a dental practice setting
Cornell, T., S.L. Westlake, and S. Richards,
Does informing patients about the link between
gum disease and rheumatoid arthritis
encourage better dental care? Rheumatology
(United Kingdom), 2012. 51: p. iii62.
Not in a dental practice setting
Craven, R.C., A.S. Blinkhorn, and L. Schou, A
campaign encouraging dental attendance
among adolescents in Scotland: the barriers to
behaviour change. Community Dental Health,
1994. 11(3): p. 131-4.
Campaign is not in a dental setting
(in schools)
DeBate, R.D., et al., Evaluate, assess, treat:
development and evaluation of the EAT
framework to increase effective communication
regarding sensitive oral-systemic health issues.
Eur J Dent Educ, 2012. 16(4): p. 232-8.
Evaluation of an intervention for
dental students education
Dela Cruz, A., et al., A community-based
randomised trial of postcard mailings to
increase dental utilization among low-income
children. Journal of Dentistry for Children
(Chicago, Ill.), 2012. 79(3): p. 154-8.
Not in a dental practice setting
Dermen, K.H., S.G. Ciancio, and J.A. Fabiano,
A pilot test of motivational oral health promotion
with alcohol-dependent inpatients. Health
Psychology, 2014. 33(4): p. 392-5.
Not in a dental setting.
Doherty, S.A. and F.C. Fielder, The effects of
health education on patients' subsequent dental
visits: a practice-based research in health
promotions. African Dental Journal, 1995. 9: p.
9-14.
Intervention is not delivered by dental staff
Dyer, T.A. and P.G. Robinson, General health
promotion in general dental practice--the
involvement of the dental team. Part 1: a review
of the evidence of effectiveness of brief public
health interventions. British Dental Journal,
2006. 200(12): p. 679-85; discussion 671.
Literature review
Ekbäck, G., C. Persson, and S. Ordell, How
much information is remembered by the
patients? A selective study related to health
education on a Swedish public health survey.
Swedish Dental Journal, 2012. 36(3): p. 143148.
Not about the effectiveness of
Health promotion messages –
its rather about whether different
groups are more likely to have
received health promotion
messages than others.
Farias, D.G., et al., Effect of oral anticipatory
guidance on oral health and oral hygiene
practices in preschool children. Journal of
Clinical Pediatric Dentistry, 2005. 30(1): p. 237.
Not in a dental practice setting
417
Oral Health: Approaches for general practice teams on promoting oral health
Ferrazzano, G.F., et al., Effectiveness of a
motivation method on the oral hygiene of
children. European Journal of Paediatric
Dentistry, 2008. 9(4): p. 183-7.
Not in a dental practice setting
Finkler, M., D.M. Belliard Oleiniski, and F.R.
Souza Ramos, Pregnant women's social
representations of oral health: A reference to
rethink mother-baby dental assistance. Online
Brazilian Journal of Nursing, 2005. 4(2): p.
11DUMMY.
Full text not available
Furusawa, M., et al., Effectiveness of dental
checkups incorporating tooth brushing
instruction. Bulletin of Tokyo Dental College,
2011. 52(3): p. 129-33.
Not in a dental practice
Greenberg, B.J.S., J.V. Kumar, and H.
Stevenson, Dental case management:
Increasing access to oral health care for
families and children with low incomes. Journal
of the American Dental Association, 2008.
139(8): p. 1114-1121.
Not in a dental setting
Griffiths, J., Patients' perception of, and
compliance with, oral hygiene instruction in a
general dental practice. Dental Health, 2002.
41(3): p. 3-6.
Doesn't provide information
on barriers or facilitators or
effectiveness of intervention
Hajimiri, K.H., G.H. Sharifirad, and A.
Hasanzade, The effect of oral health education
based on health belief model in mothers who
had 3-6 year old children on decreasing dental
plaque index in Zanjan. Journal of Zanjan
University of Medical Sciences and Health
Services, 2010. 18(72): p. 1p.
Full text not available
Hale, N.A., Community-based dental health
education in the Philippines. Journal of
Investigative Medicine, 2011. 59 (1): p. 139140.
Only abstract available - meeting
paper not full text
Harn, S.D. and D.G. Dunning, Using a
children's dental health carnival as a primary
vehicle to educate children about oral health.
Journal of Dentistry for Children, 1996. 63(4): p.
281-4.
Not in a dental clinic
Harris, R., et al., One-to-one dietary
interventions undertaken in a dental setting to
change dietary behaviour. Cochrane Database
of Systematic Reviews, 2012. 3: p. CD006540.
Systematic review
Hedman, E., K. Ringberg, and P. Gabre, Oral
health education for schoolchildren: a
qualitative study of dental care professionals'
view of knowledge and learning. International
Journal of Dental Hygiene, 2009. 7(3): p. 20411.
Not in a dental practice setting
418
Oral Health: Approaches for general practice teams on promoting oral health
Horowitz, A.M., M.Q. Wang, and D.V.
Kleinman, Opinions of Maryland adults
regarding communication practices of dentists
and staff. Journal of Health Communication,
2012. 17(10): p. 1204-1214.
The outcomes are not relevant
Houmes, S., Dental cavity prevention through
fluoride education in Sandpoint, Idaho. Journal
of Investigative Medicine, 2012. 60 (1): p. 151.
Only abstract available
meeting paper not full text
Jones, L.M. and T.J. Huggins, The rationale
and pilot study of a new paediatric dental
patient request form to improve communication
and outcomes of dental appointments. Child:
Care, Health and Development, 2013. 39(6): p.
869-872.
Not in a dental practice setting /
not about a health promotion message
Katz-Sagi, H., et al., Effects of frequent oral
hygiene instructions on microbial levels and
salivary buffer capacity in orthodontic patients
and their parents. World Journal of
Orthodontics, 2008. 9(4): p. e48-54.
Took place in a university dental clinic
Kitching, M., V. Roos, and A. Nienaber,
Educational psychology theory and the
promotion of dental care for children aged five
to six. Journal of Psychology in Africa, 2010.
20(2): p. 299-308.
Not in a dental practice setting
Knösel, M., K. Jung, and A. Bleckmann,
YouTube, dentistry, and dental education.
Journal Of Dental Education, 2011. 75(12): p.
1558-1568.
Not relevant –
and not in a dental practice setting
Laiho, M., E. Honkala, and L. Kannas, How is
oral health education conducted in Finnish
health centers? Community Dentistry and Oral
Epidemiology, 1995. 23(2): p. 119-24.
provides survey information on
prevalence of certain behaviours
rather than barriers and
facilitators on implementing oral
health messages
Lawrence, A., Dental health educators in
general practice have small impact. EvidenceBased Dentistry, 2004. 5(1): p. 15.
Commentary not study - the study
is included (Blinkhorn et al)
Makuch, A. and K. Reschke, Playing games in
promoting childhood dental health. Patient
Education and Counseling, 2001. 43(1): p. 105110.
Not a dental practice setting
Marino, R.J., et al., Cost-minimization analysis
of a tailored oral health intervention designed
for immigrant older adults. Geriatrics and
gerontology international, 2014. 14(2): p. 33640.
Setting: community groups and
dental hospital
419
Oral Health: Approaches for general practice teams on promoting oral health
Martignon, S., et al. Oral-health workshop
targeted at 0-5-yr. old deprived children's
parents and caregivers: effect on knowledge
and practices. Journal of clinical pediatric
dentistry, 2006. 31, 104-8
Not in a dental practice setting
Mayer, M.P., et al. Long-term effect of an oral
hygiene training program on knowledge and
reported behaviour. Oral health and preventive
dentistry, 2003. 1, 37-43.
Not in a dental practice setting
McConaughy, F.L., S.E. Toevs, and K.M.
Lukken, Adult clients' recall of oral health
education services received in private practice.
Journal of Dental Hygiene, 1995. 69(5): p. 20211.
Not in a dental practice setting.
Misra, S., et al., Dentist-patient communication:
What do patients and dentists remember
following a consultation? Implications for
patient compliance. Patient Preference and
Adherence, 2013. 7: p. 543-549.
Limited relation to health messages
Mun, S.J., et al., Reduction in dental plaque in
patients with mental disorders through the
dental hygiene care programme. International
Journal of Dental Hygiene, 2014. 12(2): p. 13340.
Not in a dental practice setting
Murphy, M., et al., Considerations and lessons
learned from designing a motivational
interviewing obesity intervention for young
people attending dental practices: a study
protocol paper. Contemp Clin Trials, 2013.
36(1): p. 126-34.
Study protocol - not full trial –
no outcomes reported
Newton, J.T., The readability and utility of
general dental practice patient information
leaflets: an evaluation. British Dental Journal,
1995. 178(9): p. 329-32.
Article is about NHS leaflets
which provide professional
details about dentists at surgeries
rather than oral health messages.
Also the outcome is a readable
leaflet and not any change in
peoples' knowledge or attitude.
Nishimura, M., et al., Influences of diet on
caries activities and caries-risk grouping in
children, and changes in parenting behaviour.
Pediatric Dental Journal, 2012. 22(2): p. 117124.
Public Health initiative as
opposed to a practice
based intervention.
Parlani, S., A. Tripathi, and S.V. Singh,
Increasing the prosthodontic awareness of an
aging Indian rural population. Indian Journal of
Dental Research, 2011. 22(3): p. 367-70.
Not in a dental practice
420
Oral Health: Approaches for general practice teams on promoting oral health
Pilebro, C. and B. Bäckman, Teaching oral
hygiene to children with autism. International
Journal Of Paediatric Dentistry / The British
Paedodontic Society [And] The International
Association Of Dentistry For Children, 2005.
15(1): p. 1-9.
Not in Dental practice setting
Plutzer, K. and M.J.N.C. Keirse, Incidence and
prevention of early childhood caries in one- and
two-parent families. Child: Care, Health and
Development, 2011. 37(1): p. 5-10.
Not in a dental practice setting
Plutzer, K. and A.J. Spencer, Efficacy of an oral
health promotion intervention in the prevention
of early childhood caries. Community Dentistry
and Oral Epidemiology, 2008. 36(4): p. 335-46.
Not in a dental practice setting
Primosch, R.E., C.M. Balsewich, and C.W.
Thomas, Outcomes assessment an
intervention strategy to improve parental
compliance to follow-up evaluations after
treatment of early childhood caries using
general anesthesia in a Medicaid population.
Journal of Dentistry for Children, 2001. 68(2): p.
102-8, 80.
Not in a conventional dental practice
Ramsdale, M.P. and D.P. Landes, Evaluation
of an oral health promotion pilot in County
Durham and Darlington. International Journal of
Health Promotion and Education, 2014. 52(2):
p. 60-67.
Not delivered in a dental practice
Rantanen, M., et al., Dental patient education:
a survey from the perspective of dental
hygienists. International Journal Of Dental
Hygiene, 2010. 8(2): p. 121-127.
Provides general information on
percentage of advice are given
but nothing about effectiveness
and barriers/facilitators
Reinhardt, C.H., et al. Comparison of three
forms of teaching - a prospective randomised
pilot trial for the enhancement of adherence.
International journal of dental hygiene, 2012.
10, 277-83 DOI: 10.1111/j.16015037.2011.00543.x.
Not in a dental practice
Richards, W., Evaluating oral health promotion
activity within a general dental practice. British
Dental Journal, 2013. 215(2): p. 87-91.
Not applicable - Focuses on
oral health behaviours rather
than messages in particular
Rodrigues, C.R., et al., The effect of training on
the ability of children to use dental floss. ASDC
Journal Of Dentistry For Children, 1996. 63(1):
p. 39-41.
Not in a dental practice setting
Rosseel, J.P., et al., Patient-reported feedback
promotes delivery of smoking cessation advice
by dental professionals. International Journal of
Health Promotion and Education, 2012. 50(3):
p. 101-110.
Smoking cessation
421
Oral Health: Approaches for general practice teams on promoting oral health
Rothe, V., et al., Effectiveness of a presentation
on infant oral health care for parents.
International Journal of Paediatric Dentistry,
2010. 20(1): p. 37-42.
Not in a dental practice
Sallam, A.a.M., S.B.Y. Badr, and M.A. Rashed,
Effectiveness of audiovisual modeling on the
behavioural change toward oral and dental care
in children with autism. Indian Journal of
Dentistry, 2013. 4(4): p. 184-190.
Not in a dental practice
Särner, B., et al., Recommendations by dental
staff and use of toothpicks, dental floss and
interdental brushes for approximal cleaning in
an adult Swedish population. Oral Health and
Preventive Dentistry, 2010. 8(2): p. 185-194.
Provides general information
on percentage of advice
are given but nothing about
effectiveness and barriers/facilitators
Schlueter, N., J. Klimek, and C. Ganss,
Relationship between plaque score and videomonitored brushing performance after repeated
instruction--a controlled, randomised clinical
trial. Clin Oral Investig, 2013. 17(2): p. 659-67.
Intervention took place in a
university dental clinic
Schlueter, N., et al., Adoption of a
toothbrushing technique: a controlled,
randomised clinical trial. Clin Oral Investig,
2010. 14(1): p. 99-106.
Intervention took place in a
university dental clinic
Schmiege, S.J., W.M.P. Klein, and A.D. Bryan,
The effect of peer comparison information in
the context of expert recommendations on risk
perceptions and subsequent behaviour.
European Journal of Social Psychology, 2010.
40(5): p. 746-759.
Not in a dental practice setting
Schoonheim-Klein, M., C. Gresnigt, and U. van
der Velden, Influence of dental education in
motivational interviewing on the efficacy of
interventions for smoking cessation. European
Journal of Dental Education, 2013. 17(1): p.
e28-33.
About the education of dental
students and subject area is
smoking cessation
Schou, L. and C. Wight, Does dental health
education affect inequalities in dental health?
Community Dental Health, 1994. 11(2): p. 97100.
Not in a dental practice setting
Schüz, B., et al. Effects of a short behavioural
intervention for dental flossing: randomisedcontrolled trial on planning when, where and
how. Journal of clinical periodontology, 2009.
36, 498-505 DOI: 10.1111/j.1600051X.2009.01406.x.
Not in a dental practice setting
Sharma, R., et al. Mobile-phone text messaging
(SMS) for providing oral health education to
mothers of preschool children in Belgaum City.
Journal of telemedicine and telecare, 2011. 17,
432-6
Not in a dental practice setting
422
Oral Health: Approaches for general practice teams on promoting oral health
Sherman, D.K., J.A. Updegraff, and T. Mann,
Improving oral health behaviour: a social
psychological approach. Journal of the
American Dental Association, 2008. 139(10): p.
1382-7.
Not in a dental setting, review
of previous studies
Stephens, C.D. and J. Cook, Attitudes of UK
consultants to teledentistry as a means of
providing orthodontic advice to dental
practitioners and their patients. Journal of
Orthodontics, 2002. 29(2): p. 137-42.
About education of professionals
rather than patients
Syrjälä, A.M., M.L. Knuuttila, and L.K. Syrjälä,
Self-efficacy perceptions in oral health
behaviour. Acta Odontologica Scandinavica,
2001. 59(1): p. 1-6.
Took place in a university
dental clinic
Tam, M.L., Early childhood caries prevention in
Hardin, Montana: Patient education, "first tooth.
First exam," and fluoride varnish. Journal of
Investigative Medicine, 2014. 62 (1): p. 247.
Only abstract available –
meeting paper not full text
Tilliss, T.S.I., et al., The Transtheoretical Model
applied to an oral self-care behavioural change:
development and testing of instruments for
stages of change and decisional balance.
Journal of Dental Hygiene, 2003. 77(1): p. 1625.
Weinstein, P., Provider versus patient-centered
approaches to health promotion with parents of
young children: what works/does not work and
why. Pediatric dentistry, 2006. 28(2): p. 172176; discussion 192-198.
Article is about behavioural
change rather than oral health
promotion messages
Wendt, L.K., G. Koch, and A.L. Hallonsten,
Parental awareness of dental caries in toddlers.
Swedish Dental Journal, 1996. 20(4): p. 161-4.
Not delivered in a dental practice
Wennhall, I., et al., Outcome of an oral health
outreach programme for preschool children in a
low socioeconomic multicultural area.
International Journal Of Paediatric Dentistry /
The British Paedodontic Society [And] The
International Association Of Dentistry For
Children, 2008. 18(2): p. 84-90.
Not in a dental practice setting
Yokoyama, Y., et al., Dentists' practice patterns
regarding caries prevention: Results from a
dental practice-based research network. BMJ
Open, 2013. 3(9).
Provides general information
on percentage of advice
are given but nothing about
effectiveness and barriers/facilitators
Mongeau, S. W. Horowitz, A. M., Assessment
of Reading Level and Content Adequacy of
Oral Cancer Educational Materials from USAF
Dental Clinics. Journal of Cancer Education,
2004. 19(1): pp.29-36.
Not an oral health promotion
intervention with a patient outcome.
A review of material/information
Not a study - a review
423
Oral Health: Approaches for general practice teams on promoting oral health
Bailit, H., et al., Financial issues in communitybased clinical dental education programs.
Journal of Dental Education, 1999. 63(12): p.
902-8.
Not about oral health promotion
messages - not relevant.
Cooper, B.R., Patient education software:
technology in the dental office. Dental assistant
2007. 76(3): p. 16-17.
Not a study
O'Farrell, M., Developing oral health promotion
in general dental practice in East London.
British dental nurses' journal 1996. 55(4): p. 1718.
No relevant outcomes
Massotto, M., Handling broken appointments,
low case acceptance, and high stress through
patient education. J N J Dent Assoc, 2006.
77(2): p. 17-8.
Not a study
Weinstein, P., et al., Treatment fidelity of brief
motivational interviewing and health education
in a randomised clinical trial to promote dental
attendance of low-income mothers and
children: Community-Based Intergenerational
Oral Health Study "Baby Smiles". BMC Oral
Health, 2014. 14(1): p. 1-16.
Not in a dental practice setting
Ueno, M., et al., Effects of an oral health
education program targeting oral malodor
prevention in Japanese senior high school
students. Acta Odontologica Scandinavica,
2012. 70(5): p. 426-431.
Full text not available
Jain, C., et al., Randomised controlled trial:
parental compliance with instructions to remain
silent in the dental operatory. Pediatric
Dentistry, 2013. 35(1): p. 47-51.
Not about oral health promotion
messages
Harnacke, D., et al., Oral and written instruction
of oral hygiene: a randomised trial. Journal of
Periodontology, 2012. 83(10): p. 1206-1212.
Not in a dental practice
Esfahanizadeh, N., Dental health education
programme for 6-year-olds: a cluster
randomised controlled trial. European Journal
of Paediatric Dentistry, 2011. 12(3): p. 167-170.
Not in a dental practice
Gathece, L.W., et al., Effect of health education
on oral hygiene and gingival status of persons
living with HIV attending comprehensive care
centres in Nairobi, Kenya. African Journal of
AIDS Research (AJAR), 2011. 10(4): p. 495500.
Not in a dental practice setting
424
Oral Health: Approaches for general practice teams on promoting oral health
Roberts-Thomson, K.F., et al., A
comprehensive approach to health promotion
for the reduction of dental caries in remote
Indigenous Australian children: a clustered
randomised controlled trial. International Dental
Journal, 2010. 60(3 Suppl 2): p. 245-249.
Not in a dental practice
Cardenas, L.M. and D.D. Ross, Effects of an
oral health education program for pregnant
women. Journal of the Tennessee Dental
Association, 2010. 90(2): p. 23-27.
Distributing educational information to prenatal
clinics
Ribeiro, D.G., et al., Effect of oral hygiene
education and motivation on removable partial
denture wearers: longitudinal study.
Gerodontology, 2009. 26(2): p. 150-156.
Not in a dental practice
Blinkhorn, F., et al., A phase II clinical trial of a
dental health education program delivered by
aboriginal health workers to prevent early
childhood caries. BMC Public Health, 2012. 12:
p. 681-681.
Study protocol
DiClemente, R.J., Planning models are critical
for facilitating the development,
implementation, and evaluation of dental health
promotion interventions. Journal of Public
Health Dentistry, 2011. 71: p. S16-S16.
Not a study
For the dental patient... Surfing for substance:
evaluating oral health information on the
Internet. Journal of the American Dental
Association (JADA), 2006. 137(5): p. 692-692.
Not a study – A leaflet
Bruerd, B., Focus groups: evaluating oral
health education materials. Dental Hygienist
News, 1995. 8(2): p. 21-22.
Full text not available
Lembariti, B. S., van der Weijden, G. A. and van
Palenstein Helderman, W. H. (1998), The effect of a
single scaling with or without oral hygiene instruction
on gingival bleeding and calculus formation. Journal
of Clinical Periodontology, 25: 30–33.
Mentions schools rather than
dental practice
Rong, W. S., Bian, J. Y., Wang, W. J. and De Wang,
J. (2003), Effectiveness of an oral health education
and caries prevention program in kindergartens in
China. Community Dentistry and Oral Epidemiology,
31: 412–416.
Not in a dental practice setting
Ellwood, R. P., Davies, G. M., Worthington, H. V.,
Blinkhorn, A. S., Taylor, G. O. and Davies, R. M.
(2004), Relationship between area deprivation and
the anticaries benefit of an oral health programme
providing free fluoride toothpaste to young children.
Community Dentistry and Oral Epidemiology,
32: 159–165.
Not in a dental practice setting
425
Oral Health: Approaches for general practice teams on promoting oral health
Strippel, H. (2010) Effectiveness of structured
comprehensive paediatric oral health education
for parents of children less than two years of
age in Germany. Community dental health, 27
(2), 74-80
Not in a dental practice
Freudenthal JJ; Bowen DM (2010 Winter)
Motivational interviewing to decrease parental
risk-related behaviours for early childhood
caries.
Not a dental practice setting
Lee, J.Y., Divaris, K., Baker, A.D., Rozier, R.G.,
Vann, W.F. Jr. (2012) The Relationship of Oral
Health Literacy and Self-Efficacy With Oral
Health Status and Dental Neglect. American
Journal of Public Health, May;102(5) 923-9
Population attending Women,
Infants, and Children's clinic –
not a dental practice setting
Vysniauskaite, S. and M.M. Vehkalahti,
Professional guidance on and self-assessed
knowledge of oral self-care as reported by
dentate elderly patients in Lithuania. Oral
Health & Preventive Dentistry, 2007. 5(3): p.
193-9.
No relevant outcomes
Clayton, M., et al., An Initial, Qualitative
Investigation of Patient-Centered Education in
Dentistry. Studies in Health Technology &
Informatics, 2013. 183: p. 314-318.
No relevant outcomes
Ziebolz, D., et al., Individual versus group oral
hygiene instruction for adults. Oral Health &
Preventive Dentistry, 2009. 7(1): p. 93-99.
Not in a dental practice setting
Davies, G.M., Duxbury, J.T., Boothman, N.J.,
Davies, R.M., Blinkhorn, A.S. (2005) A staged
intervention dental health promotion
programme to reduce early childhood caries.
Community dental health, 22(2), 118-22
Not in a dental practice setting
Miller, P.M., Ravenel, M.C., Shealy, A.E.,
Thomas, S. (2006) Alcohol screening in dental
patients: the prevalence of hazardous drinking
and patients' attitudes about screening and
advice. Journal of the American Dental
Association,137(12), 1692-8
Sharma, R., Hebbel, M., Ankola, A.V.,
Murugabupathy, V. (2011) Mobile-phone text
messaging (SMS) for providing oral health
education to mothers of preschool children in
Belgaum City. Journal of telemedicine and
telecare, 17(8) 432-436
Dermen, K.H., Ciancio, S.G., Fabiano J.A.
(2014) A pilot test of motivational oral health
promotion with alcohol-dependent inpatients.
Health psychology: official journal of the
Division of Health Psychology, American
Psychological Association, 33(4), 392-5
Not in a dental practice setting
Not in a dental practice setting
Not in a dental practice setting and duplicate
Not in a dental practice setting
426
Oral Health: Approaches for general practice teams on promoting oral health
Appendix D Smoking Cessation Studies
Our search strategy revealed a considerable number of studies focussing on the delivery of
smoking cessation advice. The majority of the smoking cessation studies identified were not
specifically about promoting oral health per se. It was therefore decided, in consultation with
the CPH team, that while we would endeavour to undertake a brief narrative synthesis, in
order to be able to make a “state-of –the-art” statement about smoking cessation advice via
dental surgeries, this would not be part of the main review.
A number of studies focused on the effectiveness of communicating messages about
smoking cessation in a dental surgery environment (82 trials). Whilst screening these studies
against the inclusion criteria, two studies clearly reported that these messages incorporated
communication on the negative impact of smoking on oral health. These two studies
therefore had outcomes relevant to the purpose of the main review, and so were included in
it.1,2 A further two studies4,5 were excluded as one was unobtainable5, and the other did not
meet our inclusion criteria6 as it was a qualitative study identifying strategies to design a
smoking cessation advice intervention.
The remaining studies focused predominantly on smoking cessation and smoking related
outcomes. Most of the related randomised controlled trials up to 2011 had already been
appraised and reviewed in a Cochrane review6 on smoking cessation. That review
concluded that behavioural interventions for tobacco cessation which incorporate an oral
examination may increase tobacco abstinence rates among both cigarette smokers and
smokeless tobacco users. A further Evidence Review also considered papers published
before 20117 and reported randomised controlled trials and qualitative studies conducted in
the UK. This review concluded that NHS practitioners felt that a lack of reimbursement from
the NHS, a lack of time and training, and fears over patient response acted as barriers to
delivering smoking cessation interventions. One article published in 20043 which was not
included in the Cochrane Review, concerned the framing of oral health messages, in
particlular those targeted at quitting smoking. It was found that when presented with either
positively- or negatively-framed messaged embedded in a brochure, significantly more
brochures were taken if the message was positively-framed. The authors concluded that
smokers were more receptive to information that emphasises the benefits of quitting. Four
randomised controlled trials were identified which were published after the previous
Cochrane review.8-11 Three of these studies researched technology- assisted programmes.
One study evaluated an e-system for referring smokers to a smoking cessation programme.
It offered some evidence that the e-technology encouraged higher rates of cessation,
however further studies are required to confirm this.10 Another study evaluated computerassisted guidance integrated in electronic patient records. The rates of smoking cessation
were not measured.11 These two studies would therefore have no effect on the conclusions
drawn from the Cochrane review. However, the fourth study8 evaluated interactive education
combined with motivational emails to encourage dentists to deliver brief behavioural and
smoking counselling. This behavioural intervention did not significantly decrease the rate of
cessation.
427
Oral Health: Approaches for general practice teams on promoting oral health
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
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Humphris, G.M., R. Freeman, and H.M. Clarke Risk perception of oral cancer in
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Houston, T.K., et al., Cluster-randomized trial of a web-assisted tobacco quality
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Nohlert, E., et al., Long-term follow-up of a high- and a low-intensity smoking
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Ray, M.N., et al., Smoking-Cessation e-Referrals: A National Dental Practice–Based
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Rindal, D.B., et al., Computer-assisted guidance for dental office tobacco-cessation
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428
Professor Liz Kay
Foundation Dean
Peninsula Dental School
Room C520
Portland Square
Drake Circus
Plymouth
Devon PL4 8AA
t
01752 586800
w www.plymouth.ac.uk
e
[email protected]